Bacteriological Spectrum of Post Operative Orthopedic Implant Infections and Their Antibiogram

Transcription

1 ISSN ORIGINAL ARTICLE Bateriologial Spetrum of Post Operative Orthopedi Implant Infetions and Their Antibiogram 1* 1 Satya Chandrika V, Surya Kirani KRL 1 Department of Mirobiology, Rangaraya Medial College, Kakinada (Andhra Pradesh) India Abstrat: Bakground: Infetion is a major problem in orthopedis leading to implant failure and in severe ases, amputation and even mortality. Aim and Objetives: The aim of this study is to isolate and identify organisms from postoperative Orthopaedi implant infetions and determine their antibiogram. Method and Materials: This prospetive study was onduted on 50 ases of infeted implants from Orthopaedis ward, Government General Hospital, st st Kakinda from 1 June 2014 to 1 November 2014 after obtaining learane from Institutional Ethis Committee. Pus samples were olleted using two sterile swabs. One is used for Gram's stain and the other for inoulation on MaConkey and Blood agar. Isolates were identi ed aording to the standard protools and antibioti sensitivity was done by Kirby Bauer's dis diffusion tehnique. Results: Out of 50 samples, 45(90%) were ulture positive and 5(10%) were sterile for aerobi bateria. Staphyloous aureus (30%) is ommon isolate followed by Coagulase Negative Staphylooi (CONS) (20%), Esherihia oli (16%), Klebsiella sps (10%), Pseudomonas aeruginosa (6%), Ainetobater speies (4%), Proteus speies (4%). Most of Gram positive oi are resistant to Methiillin (64%) followed by Cipro oxin (36%) and Cotrimoxazole (28%). They were mostly sensitive to Vanomyin, Linezolid, Amoxyillin Clavulani aid and Cefotaxime. Gram negative bailli are resistant to Cotrimoxazole (65%) followed by Cipro oxain (60%) and Ceftriaxone (60%) and sensitive to Carbapenems (80%), Piperaillin Tazobatam (60%) and Amoxyillin Clavulani aid (60%). Extended Spetrum Beta Latamase (ESBL) prodution is seen in 60% of Gram negative bailli. Conlusions: The inidene of multidrug resistane pathogens as a ause of implant infetions is rising. Adequate preventive measures should be enfored to prevent the spread of antibioti resistant organisms. Keywords: Orthopedi implant infetions, Bateriologial pro le, Antibiogram, Extended Spetrum Beta Latamase Introdution: Infetion is a major problem in orthopedi implantations leading to implant failure. It is a hallenging task to treat orthopedi implant infetions whih may lead to implant replaement and in severe ases, amputation and even mortality. Soures of infetious bateria inlude environment of the operating room, surgial equipment, lothing worn by medial and paramedial staff and resident bateria on the patient's skin. Implant-assoiated infetions are the result of baterial adhesion to an implant surfae and subsequent bio lm formation at the implantation site. Eah hospital has its own Journal of Krishna Institute of Medial Sienes University 20

2 unique baterial ora to whih patients are at risk for aquiring infetion during hospitalization. In suh situations; miroorganism exhibit unique pattern of antimirobial ativity during a ertain period of time [1]. Sine initial antibioti therapy is empirial, it is important to know prevailing antibioti suseptibility patterns of individual institutions by routine surveillane [2]. In the reent years the organisms isolated from these infeted ases are showing inreased resistane to ommonly used rst line antibiotis and multi-drug resistane. Methiillin resistane has beome most ommon and most organisms isolated are also Extended Spetrum Beta Latamase (ESBL) produers. The objetives of this study are to determine the spetrum of aerobi baterial isolates from postoperative orthopedi implant infetions and to determine their antimirobial suseptibility patterns. The pus samples were olleted aseptially on the rst day when patients presented with linial evidene of infetion (purulent drainage from inision or drain), using two sterile otton swabs from surgial site without ontaminating with skin ommensals and transported to the laboratory immediately. Speimens olleted were subjeted to diret mirosopy by Gram's staining. For ulture, the speimens were inoulated onto MaConkey and blood agar (Fig.1 and Fig. 2). Preliminary identi ation of bateria was done by the olony harateristis and Gram staining. Further identi ation was done by a set of biohemial tests. Antimirobial suseptibility pattern of isolated baterial pathogens were determined by Kirby Bauer Dis Diffusion Method (KBDDM) aording to CLSI guidelines [3-5]. Material and Methods: This prospetive study was onduted on 50 ases of infeted implants from Orthopedi ward, from June 2014 to November 2014 after obtaining institutional ethial ommittee learane. Inlusion Criteria: Patients with purulent disharge from inision or drain within a week after surgery and also after few weeks after disharge from hospital of all age groups and both sexes were seleted. Exlusion Criteria: 1) Use of antibiotis after diagnosis of infetion. 2) Implantation done through already infeted wound. Fig.1 Golden Yellow Colonies of Staphyloous aureus on Blood Agar Journal of Krishna Institute of Medial Sienes University 21

3 Enterobateriaeae isolates with Cefotaxime and Ceftazidime zones of inhibition less than 27 mm, 22 mm, respetively were suspeted to be ESBL produing [3, 4]. A on rmatory test using the Double Dis Synergy tehnique was arried out aording to CLSI guidelines [7] (Fig.4). Fig. 2: Latose Fermenting Colonies on MaConkey Agar Methiillin resistane was identi ed by using Cefoxitin (30 μg) dis. Aording to the Clinial and Laboratory Standards Institute (CLSI) a zone of growth inhibition around the Cefoxitin disk 22 mm was identi ed as Methiillin Sensitive Staphyloous aureus and <22 mm was identi ed as Methiillin Resistant Staphyloous aureus [6] (Fig.3). Fig. 4: Double Dis Synergy Test on Muller Hinton Agar Plate Results: Fig. 3: Cefoxitin Resistane on Muller Hinton Agar Plate Out of the 50 samples, 45(90%) ulture were positive and 5(10%) ulture were negative. Out of 45 ulture positive ases 25(55.6%) were Gram positive oi and 20(44.4%) were Gram negative bailli. Staphyloous aureus (33.3%) was the most ommon isolate followed by Coagulase negative Staphylooi (22.2%), Esherihia oli ( % ), K l e b s i e l l a s p e i e s ( % ), Pseudomonas speies (6.7%), Ainetobater speies (4.4%) and Proteus speies (4.4%). (Fig. 5) Journal of Krishna Institute of Medial Sienes University 22

4 Fig. 5: Organisms Isolated from Postoperative Orthopaedi Implant Infetions Antibiogram of Gram positive oi showed highest resistane to Cefoxitin (64%) followed by Peniillin (60%), Cipro oxain (36%), Cotrimoxazole (28%), Levo oxain (16%), Amikain (8%) and Gentamiin (4%). Amoxylav, Cefotaxime, Linezolid and Vanomyin did not show any resistane. (Fig. 6) Fig. 6: Antibiogram of Gram Positive Coi Journal of Krishna Institute of Medial Sienes University 23

5 Antibiogram of Gram negative bailli showed highest resistane to Cotrimoxazole (65%) followed by Ceftriaxone (60%),Cipro oxain (60%),Cefotaxime (55%), Ampiillin (50%), Ceftazidime (45%), Piperaillin Tazobatum (40%),Amoxylav (35%), Imipenem (20%) and Gentamiin (10%). (Fig. 7) Fig. 7: Antibiogram of Gram Negative Bailli Methiillin resistane was seen in 66.6% isolates of Staphyloous aureus and 60% isolates of Coagulase negative Staphyloous aureus. ESBL prodution is seen in 60% of Gram negative bailli. Disussion: The purpose of the study was to isolate the aerobi organisms ausing orthopedi implant infetions and to know their resistane pattern with referene to Methiillin sensitivity and ESBL prodution. Out of 50 samples, 45(90%) have been ulture positive and 5 (10%) sterile for aerobi bateria. In ulture positive samples Gram positive oi (55.6%) are more than Gram negative bailli (44.4%). In our study Staphyloous aureus(33.3%) was the most ommon isolate and orrelates to earlier studies by Goel et al 2013(32.8%)[8], Sonawane et al 2010(29.26%) [2] and Jain et al 2014(26.6%) [1] (Table 1). Journal of Krishna Institute of Medial Sienes University 24

6 Table 1: Comparison with Other Studies Sonawane et al 2010 Goel et al 2013 Jain et al 2014 Present Study 2014 Common Isolate Staphyloous aureus (32.8%) Staphyloous aureus (26.6%) Staphyloous aureus (33.3%) GPC Resistane Peniillin (75.32%) Cotrimoxazole (69.9%) Cipro oxain (47.5%) Cotrimoxazole (32.5%) Peniillin (89.1%) Oxaillin (93.75%) Cefoxitin (64%) Peniillin (60%) Cipro oxain (36%) GNB Resistane Ampiillin (88%) Ceftriaxone (69.8%) Ceftazidime (69.8%) Cefuroxime (81.5%) Cefotaxime (78%) Amoxylav (80.8%) Ceftriaxone (76%) Cotrimoxazole (65%) Cipro oxain (60%) Ceftriaxone (60%) Methiillin Resistane ESBL Prodution 27.85% 30% 40% 64% 71.72% % GPC-Gram positive oi, GNB-Gram negative bailli, ESBL-Extended spetrum beta latamase In our study methiillin resistane is 64% whih does not orrelate with other studies and ESBL prodution is 60% whih orrelates with Sonawane et al 2010(71.72%) [2]. The inidene of Methiillin Resistant Staphyloous Aureus (MRSA) in India ranges from 30-70% [9]. The inidene of nosoomial infetions whih are aused by MRSA ontinues to inrease; therefore, the importane of their detetion, espeially for treatment and epidemiologial purposes [9]. In our study, Gram positive oi have shown highest resistane to Methiillin, but it showed resistane to Peniillin in studies by Sonawane et al 2010 [2] and Jain et al 2014 [1] and it showed resistane to Cipro oxin in the study by Goel et al 2013 [8]. In our study Gram negative bailli showed a highest resistane to Cotrimoxazole followed by Cipro oxain and Ceftriaxone, whereas it is Ampiillin followed by Ceftriaxone in the study by Sonawane et al 2010, Cefuroxime and Cefotaxime in the study by Goel et al 2013 [8] and Amoxylav and Ceftriaxone in the study by Jain et al 2014 [1]. Our study has shown that Staphyloous aureus, CONS, Esherihia oli, Klebsiella sps and Pseudomonas aeruginosa were the major Journal of Krishna Institute of Medial Sienes University 25

7 baterial pathogens ausing implant infetions in our area. Contamination from the external environment may be a possible reason for the higher rate of Surgial Site Infetions (SSI) in orthopaedi surgeries [9]. The pathogenesis of infetion in fratures xation devies is related to miro- organisms, whih grow in bio lm, and therefore its eradiation is dif ult [10]. Conlusion: A high inidene of methiillin resistane and ESBL prodution was observed in orthopedi implant infetions. The inidene of multi-drug resistant pathogens as a ause of implant infetions is also rising. So, adequate preventive measures should be enfored to prevent the spread of antibioti resistant organisms. 1. Arti Jain, Sunita Bhatawadekar, MeeraModak. Bateriologial pro le of surgial site infetion from a tertiary are hospital, from western India. Indian Journal of Applied Researh 2014; 4: Jyoti Sonawane, Narayan Kamanth, Rita Swaminathan, Kaushal Dosani.Bateriologial pro le of surgial site infetions andtheir antibiogram in teritiary hospitals in Navi Bombay. Bombay Hospital Journal 2010;52: Laboratory methods and Strategies for antimirobial suseptibility testing. In: Patriia M.Tille, editor. th BaileyandSott's Diagnosti Mirobiology, 13 ed.new Delhi: Elsevier R.S. Miles, S.G.B. Amyes. Laboratory ontrol of antimirobial therapy. In: J.Gerald Collee, editor. th Makie MCartney Pratial Mirobiology, 14 ed. Kundli: Elsevier p Clinial Laboratory Standards Institute Performane standards for antimirobial disk suseptibility tests; Approved standard 9th ed. CLSI doument M2-A9. 26:1. Clinial Laboratory Standards Institute, Wayne, PA. Referenes 6. CLSI Performane standards for antimirobial suseptibility testing; 17th informational supplement. CLSI M100-S17. CLSI, Wayne, PA. 7. Clinial and Laboratory Standards Institute. Performane standards for antimirobial suseptibility testing; nineteenth informational supplement M100- S19. Wayne, PA: Clinial and Laboratory Standards Institute; Nitin Goel Insan, Nikhil Payal, Mahesh Singh, Amod Yadav, B.L Chaudhary, Ambrish Srivastava. Post operative wound infetion bateriology and antibioti sensitivity pattern. IJCRR 2013; 5: Gayathree Naik, Srinivas R. Deshpande. A Study on Surgial Site Infetions Caused by Staphyloous aureus with a Speial Searh for Methiillin-Resistant Isolates. Journal of Clinial and Diagnosti Researh 2011; 5: Muhammad Shoaib Khan, Saifur Rehman, Mian Amjad Ali, Babar Sultan, Shahid Sultan. Infetion in orthopedi implant surgery, its risk fators and outome. J Ayub Med Coll Abbottabad 2008;20:23-5 *Author for Correspondene: Dr. Venna Satya Chandrika, Department of Mirobiology, Government General Hospital, Kakinada, Andhra Pradesh India drsatyahandrika85@gmail.om Cell: Journal of Krishna Institute of Medial Sienes University 26