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Bajare B, Dhangar A, Tankhiwale S, Shrikhande S. Bacteriological profile of pyogenic infections and their antimicrobial susceptibility in a tertiary care hospital in central India. mljgoums 2024; 18 (2) :16-18
URL: http://mlj.goums.ac.ir/article-1-1637-en.html
URL: http://mlj.goums.ac.ir/article-1-1637-en.html
1- Government medical college and hospital, Nagpur, Maharashtra, India , bhavnabajare@gmail.com
2- Government medical college and hospital, Nagpur, Maharashtra, India
2- Government medical college and hospital, Nagpur, Maharashtra, India
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Introduction
Globally, infectious diseases have become the major and important causes of morbidity and mortality, whether in the community or hospital settings. Each year, nearly 25% of estimated deaths are due to infectious diseases out of a total of 60 million deaths worldwide (1). The crude mortality rate due to infectious diseases in India is approximately 417 per one lakh population (2).
Pyogenic infections are infections involving the production of pus at the site of local inflammation of the skin, soft tissue, and other body parts caused by the invasion and multiplication of pathogenic microorganisms (3). During infection, macrophages release cytokines, triggering neutrophils to reach the site of infection by chemotaxis. There, neutrophils release granules, which destroy the bacteria. The bacteria resist the immune response by releasing toxins called leucocidins. As the neutrophils die off from toxins and old age, they are destroyed by macrophages, forming the viscous pus (4).
If proper care is not initiated promptly, pyogenic infection leads to sepsis. In developing countries, reports of suppurative wound infections are as high as 40%, compared to developed countries, which are around 3% to 11% (5). Hence appropriate antimicrobial treatment should be started at the right time. Over the years, poor antimicrobial stewardship in India has led to an increase in multidrug-resistant (MDR) superbugs in both community and hospital settings.
This study aims to determine the bacterial isolates in such pyogenic infections followed by their antimicrobial susceptibility pattern to aid in formulating empirical therapy and implementing hospital infection control strategies to prevent multidrug resistance.
Methods
Study design
This cross-sectional study was conducted in the Department of Microbiology at a tertiary care hospital in Nagpur city from the central region of India from October 2021 to March 2022. All pus and wound swab samples from outpatient departments, inpatient departments, and intensive care units (Department of Medicine, Orthopedics, Surgery, Obstetrics and Gynecology, and various other departments) for routine microscopy, culture, and sensitivity received at the Microbiology Laboratory during the study period were included.
Isolation and identification
The specimens received were subjected to culture on Blood Agar and MacConkey Agar plates and incubated aerobically for 18-24 hours at 37 °C. Direct smears of specimens were subjected to Gram stain and observed microscopically. Inoculated plates were observed for bacterial growth. Species identification was done on the basis of morphological appearance of colonies on media, Gram stains and various biochemical tests as per standard laboratory protocol.
Antimicrobial susceptibility testing
Isolates from pus specimens were subjected to antimicrobial sensitivity test by Kirby-Bauer method as per Clinical and Laboratory Standards Institute (CLSI) 2021.
For GNB following antimicrobial discs were used:
ampicillin (10µg), amoxicillin – clavulinate (20/10µg), ceftazidime (30µg), ceftriaxone (30µg), cefepime (30µg), cefoxitin (30µg), piperacillin-tazobactam (100/10µg), aztreonam (30µg), imipenem (10µg), meropenem (10µg), gentamycin (10µg), amikacin (30µg), ciprofloxacin (5µg), levofloxacin (5µg),
trimethoprim-sulphamethoxazole/co-trimoxazole (25µg), from HiMedia Laboratories, India.
The antibiotics used for Gram-positive bacteria were as follows:
Penicillin (10U), Cefoxitin (30µg), High-Level Gentamicin
(HLG) (120µg), Levofloxacin Trimethoprim/Sulfamethoxazole
(1.25/23.75 µg), Clindamycin (2µg), Erythromycin (15 µg), Linezolid (30 µg), Vancomycin (30 µg discs), Teicoplanin (30 µg). (5)
Detection of MRSA Strains of Staphylococcus aureus
Methicillin resistance among Staphylococcus aureus isolates was tested by using cefoxitin disc (30µg) as per standard detection guidelines mentioned as per CLSI (5).
Quality Control
For quality control following were used
S. aureus (ATCC 25923)
Escherichia coli (ATCC 25922)
Pseudomonas aeruginosa (ATCC 27853)
Data Analysis
Data regarding all the isolated were entered into WHONET software and analyzed using the same. WHONET is a Windows-based database software package for managing Microbiology laboratory data and the analysis of antimicrobial susceptibility test results (6). Categorical variables have been mentioned in numerical and percentages.
Results
A total 752 pus and wound samples were received in Microbiology laboratory for culture and sensitivity during the study period. 510(68%) samples yielded positive culture and there was no growth in 242(32%) samples.
Among 510 bacterial isolates, 394(77%) Gram negative bacteria were isolated and 116 (23%) were gram positive bacteria. Among Gram negative bacteria, 261(51%) were fermenters and 133(26%) were non-fermenters. Klebsiella pneumoniae ss. pneumoniae dominated the profile and became the most common isolated organism, followed by Escherichia coli. Among gram positive bacteria Staphylococcus aureus were major isolated organism, becoming the 2nd most common isolate. (Table 1)
Staphylococcus aureus showed maximum sensitivity towards Linezolide (99.1%) followed by Doxycycline (81.1%) and least sensitivity towards penicillin. Among S.aureus, 33.1% isolates were methicillin sensitive, showing methicillin resistant S.aureus (MRSA) to be 67%.( Figure 1)
Enterococcus species showed maximum sensitivity to Linezolide (92.85%) followed by vancomycin (81.25%). Among Enterococcus spp. 18.75% were vancomycin resistant. (Figure 2)
.PNG)
.PNG)
Antimicrobial susceptibility pattern of Gram-negative isolates is shown in Figure 3 and Figure 4.
.PNG)
.PNG)
Gram negative organism were mostly sensitive to gentamicin (80%) followed by piptaz and carbapenem, and least sensitive to amoxiclav. Pseudomonas aeruginosa had maximum sensitivity to Gentamicin (89.9%) followed by tobramycin, cefepime, meropenem, and least sensitivity to Amoxiclav. Acinetobacter showed the highest sensitivity to Ampicillin-sulbactam (91.1%) followed by levofloxacin and meropenem (56.66%), and least sensitivity to ceftazidime.
Discussion
In present study Gram negative bacteria (GNB) were more compared to Gram positive bacteria (GPB) which is similar to study conducted by Gomatheswari et al, at Tamilnadu in 2016 (7).
Among GNB Klebsiella pneumoniae was the predominant organism isolated in present study (27%) with similar findings shown in studies by Sharma V et al, Krisnamurthi et al, (2020) and Gomatheswari et al. (2016) (7-9). Among GPB S. aureus was isolated in higher abundance followed by Enterococcus spp. in studies Biradar et al. (2015) and Mukherjee et al. (2019) similar to the present study. (10,11)
In a study conducted by Mukherjee et al, in HTMC, Rourkela, Odissa in 2019 Staphylococcus aureus showed high sensitivity to linezolid (92%), aminoglycoside (84%), clindamycin (88%) and cotrimoxazole (72%) but lower sensitivity to erythromycin (25%), amoxiclav (40%) and fluoroquinolones (44%) similar to the present study (10). However, in another study by Duggal et al. (2014) and Ramesh Kannan et al. (2014), Pseudomonas spp. was the most abundant organism (12,13).
The percentage of MRSA in the present study was 67%, whereas in a study conducted by Mohansundari et al. in 2020 in Rasipuran, Tamilnadu it was 50% (14). Enterococcus showed maximum sensitivity to Linezolide (92.85%) followed by Vancomycin (81.25%) similar to Batra et all, (2021) (15). Percentage of Vancomycin-resistant Enterococcus is 18.75% whereas in was 6.70% in Batra et all study (15). In a study conducted by Mukherjee et al, in HTMC, Rourkela, Odissa in 2019, most of the gram-negative bacilli showed high sensitivity towards imipenem (53-93%), meropenem (80-100%), piperacillin tazobactam (67-100%) and amikacin (67- 88%) but lower sensitivity to 3rd generation cephalosporins (36-73%), cotrimoxazole (60-80%), amoxiclav (20-75%) and fluoroquinolones (10).
As seen in Gomatheswari et al (2017), Mukherjee et al., (2020), and Gupta M et al, (2019), Trojan R et al (2016) it is stated that S. aureus and Gram- negative bacterial pathogens can produce highly potent virulence factors, which is responsible for maintaining the infection and delaying the process of recovery (7,10,16,17).The present study identified the most commonly isolated organisms causing pyogenic infection, also the existence of superbugs like MRSA and VRE.
Conclusion
This study provided us insight about prevalence and common etiology of pyogenic infections, with their antibiotic susceptibility in central region of India, which will help in formulating antibiotic stewardship for hospitals. In this study, the rate of pyogenic infections was 68%. Klebsiella pneumonia is the most predominant isolated bacteria followed by E. coli, Staphylococcus aureus and Pseudomonas spp. Among Gram positive bacteria isolated, MRSA was 67% and vancomycin resistant Enterococcus was 18.75%. Strict implementation of antimicrobial stewardship with a routinely updated antibiogram and proper infection control measures may help decrease the burden of infections with various resistant organisms in the era of challenges faced due to the globally increasing antimicrobial resistance.
Acknowledgement
NIL
Funding sources
NIL
Ethical statement
Approval from institutional ethical committee has been taken.
Conflicts of interest
NIL
Author contributions
Bhawana Bajare - Contributed in preparation of research plan, research work, data collection & analysis and manuscript preparation.
Akanksha Dhangar - Contributed in Research work, data analysis and done manuscript writing.
Supriya Tankhiwale - Contributed in manuscript preparation.
Sunanda Shrikhande - Contributed in manuscript preparation.
Globally, infectious diseases have become the major and important causes of morbidity and mortality, whether in the community or hospital settings. Each year, nearly 25% of estimated deaths are due to infectious diseases out of a total of 60 million deaths worldwide (1). The crude mortality rate due to infectious diseases in India is approximately 417 per one lakh population (2).
Pyogenic infections are infections involving the production of pus at the site of local inflammation of the skin, soft tissue, and other body parts caused by the invasion and multiplication of pathogenic microorganisms (3). During infection, macrophages release cytokines, triggering neutrophils to reach the site of infection by chemotaxis. There, neutrophils release granules, which destroy the bacteria. The bacteria resist the immune response by releasing toxins called leucocidins. As the neutrophils die off from toxins and old age, they are destroyed by macrophages, forming the viscous pus (4).
If proper care is not initiated promptly, pyogenic infection leads to sepsis. In developing countries, reports of suppurative wound infections are as high as 40%, compared to developed countries, which are around 3% to 11% (5). Hence appropriate antimicrobial treatment should be started at the right time. Over the years, poor antimicrobial stewardship in India has led to an increase in multidrug-resistant (MDR) superbugs in both community and hospital settings.
This study aims to determine the bacterial isolates in such pyogenic infections followed by their antimicrobial susceptibility pattern to aid in formulating empirical therapy and implementing hospital infection control strategies to prevent multidrug resistance.
Methods
Study design
This cross-sectional study was conducted in the Department of Microbiology at a tertiary care hospital in Nagpur city from the central region of India from October 2021 to March 2022. All pus and wound swab samples from outpatient departments, inpatient departments, and intensive care units (Department of Medicine, Orthopedics, Surgery, Obstetrics and Gynecology, and various other departments) for routine microscopy, culture, and sensitivity received at the Microbiology Laboratory during the study period were included.
Isolation and identification
The specimens received were subjected to culture on Blood Agar and MacConkey Agar plates and incubated aerobically for 18-24 hours at 37 °C. Direct smears of specimens were subjected to Gram stain and observed microscopically. Inoculated plates were observed for bacterial growth. Species identification was done on the basis of morphological appearance of colonies on media, Gram stains and various biochemical tests as per standard laboratory protocol.
Antimicrobial susceptibility testing
Isolates from pus specimens were subjected to antimicrobial sensitivity test by Kirby-Bauer method as per Clinical and Laboratory Standards Institute (CLSI) 2021.
For GNB following antimicrobial discs were used:
ampicillin (10µg), amoxicillin – clavulinate (20/10µg), ceftazidime (30µg), ceftriaxone (30µg), cefepime (30µg), cefoxitin (30µg), piperacillin-tazobactam (100/10µg), aztreonam (30µg), imipenem (10µg), meropenem (10µg), gentamycin (10µg), amikacin (30µg), ciprofloxacin (5µg), levofloxacin (5µg),
trimethoprim-sulphamethoxazole/co-trimoxazole (25µg), from HiMedia Laboratories, India.
The antibiotics used for Gram-positive bacteria were as follows:
Penicillin (10U), Cefoxitin (30µg), High-Level Gentamicin
(HLG) (120µg), Levofloxacin Trimethoprim/Sulfamethoxazole
(1.25/23.75 µg), Clindamycin (2µg), Erythromycin (15 µg), Linezolid (30 µg), Vancomycin (30 µg discs), Teicoplanin (30 µg). (5)
Detection of MRSA Strains of Staphylococcus aureus
Methicillin resistance among Staphylococcus aureus isolates was tested by using cefoxitin disc (30µg) as per standard detection guidelines mentioned as per CLSI (5).
Quality Control
For quality control following were used
S. aureus (ATCC 25923)
Escherichia coli (ATCC 25922)
Pseudomonas aeruginosa (ATCC 27853)
Data Analysis
Data regarding all the isolated were entered into WHONET software and analyzed using the same. WHONET is a Windows-based database software package for managing Microbiology laboratory data and the analysis of antimicrobial susceptibility test results (6). Categorical variables have been mentioned in numerical and percentages.
Results
A total 752 pus and wound samples were received in Microbiology laboratory for culture and sensitivity during the study period. 510(68%) samples yielded positive culture and there was no growth in 242(32%) samples.
Among 510 bacterial isolates, 394(77%) Gram negative bacteria were isolated and 116 (23%) were gram positive bacteria. Among Gram negative bacteria, 261(51%) were fermenters and 133(26%) were non-fermenters. Klebsiella pneumoniae ss. pneumoniae dominated the profile and became the most common isolated organism, followed by Escherichia coli. Among gram positive bacteria Staphylococcus aureus were major isolated organism, becoming the 2nd most common isolate. (Table 1)
Staphylococcus aureus showed maximum sensitivity towards Linezolide (99.1%) followed by Doxycycline (81.1%) and least sensitivity towards penicillin. Among S.aureus, 33.1% isolates were methicillin sensitive, showing methicillin resistant S.aureus (MRSA) to be 67%.( Figure 1)
Enterococcus species showed maximum sensitivity to Linezolide (92.85%) followed by vancomycin (81.25%). Among Enterococcus spp. 18.75% were vancomycin resistant. (Figure 2)
|
Table 1. Biological profile data of isolated organism
.PNG) |
Antimicrobial susceptibility pattern of Gram-negative isolates is shown in Figure 3 and Figure 4.
Gram negative organism were mostly sensitive to gentamicin (80%) followed by piptaz and carbapenem, and least sensitive to amoxiclav. Pseudomonas aeruginosa had maximum sensitivity to Gentamicin (89.9%) followed by tobramycin, cefepime, meropenem, and least sensitivity to Amoxiclav. Acinetobacter showed the highest sensitivity to Ampicillin-sulbactam (91.1%) followed by levofloxacin and meropenem (56.66%), and least sensitivity to ceftazidime.
Discussion
In present study Gram negative bacteria (GNB) were more compared to Gram positive bacteria (GPB) which is similar to study conducted by Gomatheswari et al, at Tamilnadu in 2016 (7).
Among GNB Klebsiella pneumoniae was the predominant organism isolated in present study (27%) with similar findings shown in studies by Sharma V et al, Krisnamurthi et al, (2020) and Gomatheswari et al. (2016) (7-9). Among GPB S. aureus was isolated in higher abundance followed by Enterococcus spp. in studies Biradar et al. (2015) and Mukherjee et al. (2019) similar to the present study. (10,11)
In a study conducted by Mukherjee et al, in HTMC, Rourkela, Odissa in 2019 Staphylococcus aureus showed high sensitivity to linezolid (92%), aminoglycoside (84%), clindamycin (88%) and cotrimoxazole (72%) but lower sensitivity to erythromycin (25%), amoxiclav (40%) and fluoroquinolones (44%) similar to the present study (10). However, in another study by Duggal et al. (2014) and Ramesh Kannan et al. (2014), Pseudomonas spp. was the most abundant organism (12,13).
The percentage of MRSA in the present study was 67%, whereas in a study conducted by Mohansundari et al. in 2020 in Rasipuran, Tamilnadu it was 50% (14). Enterococcus showed maximum sensitivity to Linezolide (92.85%) followed by Vancomycin (81.25%) similar to Batra et all, (2021) (15). Percentage of Vancomycin-resistant Enterococcus is 18.75% whereas in was 6.70% in Batra et all study (15). In a study conducted by Mukherjee et al, in HTMC, Rourkela, Odissa in 2019, most of the gram-negative bacilli showed high sensitivity towards imipenem (53-93%), meropenem (80-100%), piperacillin tazobactam (67-100%) and amikacin (67- 88%) but lower sensitivity to 3rd generation cephalosporins (36-73%), cotrimoxazole (60-80%), amoxiclav (20-75%) and fluoroquinolones (10).
As seen in Gomatheswari et al (2017), Mukherjee et al., (2020), and Gupta M et al, (2019), Trojan R et al (2016) it is stated that S. aureus and Gram- negative bacterial pathogens can produce highly potent virulence factors, which is responsible for maintaining the infection and delaying the process of recovery (7,10,16,17).The present study identified the most commonly isolated organisms causing pyogenic infection, also the existence of superbugs like MRSA and VRE.
Conclusion
This study provided us insight about prevalence and common etiology of pyogenic infections, with their antibiotic susceptibility in central region of India, which will help in formulating antibiotic stewardship for hospitals. In this study, the rate of pyogenic infections was 68%. Klebsiella pneumonia is the most predominant isolated bacteria followed by E. coli, Staphylococcus aureus and Pseudomonas spp. Among Gram positive bacteria isolated, MRSA was 67% and vancomycin resistant Enterococcus was 18.75%. Strict implementation of antimicrobial stewardship with a routinely updated antibiogram and proper infection control measures may help decrease the burden of infections with various resistant organisms in the era of challenges faced due to the globally increasing antimicrobial resistance.
Acknowledgement
NIL
Funding sources
NIL
Ethical statement
Approval from institutional ethical committee has been taken.
Conflicts of interest
NIL
Author contributions
Bhawana Bajare - Contributed in preparation of research plan, research work, data collection & analysis and manuscript preparation.
Akanksha Dhangar - Contributed in Research work, data analysis and done manuscript writing.
Supriya Tankhiwale - Contributed in manuscript preparation.
Sunanda Shrikhande - Contributed in manuscript preparation.
Research Article: Research Article |
Subject:
Microbiology
Received: 2023/03/4 | Accepted: 2024/03/6 | Published: 2024/04/29 | ePublished: 2024/04/29
Received: 2023/03/4 | Accepted: 2024/03/6 | Published: 2024/04/29 | ePublished: 2024/04/29
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