Aerobic bacterial infections in a burns unit of Sassoon General Hospital, Pune

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1 Original article Aerobic bacterial infections in a burns unit of Sassoon General Hospital, Pune Patil P, Joshi S, Bharadwaj R. Department of Microbiology, B.J. Medical College, Pune, India. Corresponding author: Dr. Priyanka Patil Abstract: Introduction: Infection in the burn patient is a leading cause of morbidity and mortality and remains one of the most challenging concerns for the burn team. For this reason we carried out a study to determine the predominant bacteria causing infections and their antimicrobial susceptibility pattern. Methods: A prospective cross sectional study over a period of three months was carried out in burns unit of Sassoon General Hospital, Pune. A total of 51 surface wound swab specimens from 39 patients were collected and processed aerobically. All were identified by conventional microbiological methods and their antibiogram was determined as per CLSI guidelines. Results: 81 were obtained from 51 specimens. Out of them, 26 (50.98%) specimens were mono-microbial while 25 (49.01%) specimens were poly-microbial. Pseudomonas aeruginosa was the most common isolate 22 (27.61%) followed by Klebsiella species 13, 16.04%), Staphylococcus aureus (MRSA) (12, 14.81%). Both gram positive and gram negative show widespread resistance to first-line antibiotics. While they are relatively sensitive to second line agents which are considered as reserved drugs. Conclusion: Our results were helpful in providing guidelines regarding empirical antimicrobial treatment in burns patients before the results of microbiological culture became available. Key words: burn wound, Antimicrobial resistance, Pseudomonas aeruginosa Introduction surveillance is needed. So the current study was Burn injury is one of the most common and undertaken to assess predominant aerobic microbial devastating forms of trauma in many areas of the flora and their antibiogram in burns unit of Sassoon world. It has been estimated that 75% of all deaths General Hospital, Pune. following thermal injuries are related to Aims & Objectives infections. (1) The rate of nosocomial infections is To determine the predominant bacteria and their higher in burn patients due to various factors like antimicrobial susceptibility pattern causing nature of burn injury itself, immunocompromised infections in burn wound patients. status of the patient, invasive diagnostic and Material & Methods therapeutic procedures and prolonged ICU stay. (2) The present study was conducted in the Department Good infection control practices have a great of Microbiology, Sassoon General Hospital, Pune. impact on survival rate of burn patients. Emerging This was a prospective cross sectional study. antimicrobial resistance in burn wound bacterial Among the admitted patients, thirty nine randomly pathogens represent a serious therapeutic challenge selected patients who gave consent were included for clinicians treating these patients. In order to the study. A total of 51 surface burn wound swabs overcome this problem continuous microbiological were collected from 39 patients (13 males &

2 females) over a period of three months from June- August Extent of burn injury ranged from (15%-70%). These Patients were not having infected wound at the time of admission. Burn wound infection was evident after one week stay in the hospital. All specimens were transported in sterile, leak-proof container to Department of Microbiology. They were processed for aerobic bacterial pathogens & were identified by conventional microbiological methods. Antimicrobial susceptibility pattern was determined as per Clinical and Laboratory Standard Institute (CLSI) guidelines. To assess the differences in the range of bacterial pathogens in male & female s, they were studied &analyzed separately. Re-sampling was done in 6 patients who were not responding to treatment. Fig. 1: Schematic Representation of Burns Unit of Sassoon General Hospital, Pune. Observation & results Out of 51 specimens, single organism was isolated in 25(49%) specimens while mixed organisms were isolated in 26(51%). Total 81 were obtained. Table 1: Distribution of aerobic bacterial (n=81) ISOLATES NO Percentage (%) Pseudomonas aeruginosa Klebsiella pneumonae MRSA Citrobacter spp Escherichia coli Proteus mirabilis 5 6 Enterobacter spp. 3 4 Acinetobacter spp. 3 4 Coagulase negative staphylococci 2 3 TOTAL

3 Pseudomonas aeruginosa 22(27%) was the commonest isolate followed by Klebsiella pneumonae 13(16%) and MRSA 12(15%). (Table 1) In this study, we have compared antibiogram of pathogens obtained from male and female s. The antibiogram of Gram negative organisms isolated from burn wound is shown in Table 2. Table 2: Antimicrobial Sensitivity Pattern of Gram negative in male & female s Escherichia coli (n=10) Citrobacter spp. (n=11) Klebsiella pneumonae (n=13) AMA AK CRO SXT G CIP T IPM PTZ Male Female Male Sensitivity n=4 n=6 n=6 Female isolate n=5 Male n=8 Female isolate n=5 NO % NO % NO % NO % NO % NO % R S R R R S R S R S R S R AMA = Antimicrobial agent, AK = Amikacin, CRO = Ceftriaxone, SXT = Cotrimoxazole, G = Gentamicin, CIP = Ciprofloxacin, T = Tetracycline, IPM = Imipenem, PTZ = Piperacillin-Tazobactum, S = Susceptible, R = Resistant. E.coli, Klebsiella spp. and Citrobacter spp. were highly resistance to first line drugs like Amikacin, Ceftriaxone, Cotrimoxazole, and Gentamicin. E.coli and Citrobacter spp. were 100% sensitive to Imipenem and Piperacillin-Tazobactum. Sensitivity pattern from both male and female s doesn t show much difference. (Table 2) Table 3: Antimicrobial Sensitivity Pattern of Pseudomonas aeruginosa in male & female s

4 AMA AK CAZ CB G CIP T IPM PTZ Pseudomonas aeruginosa (n=22) Male Female Sensitivity n=8 n=14 NO % NO % R S R S R S R S R S R S R S R AMA = Antimicrobial agent, AK = Amikacin, CAZ = Ceftazidime, CB = Carbenicillin, G = Gentamicin, CIP = Ciprofloxacin, T = Tetracycline, IPM = Imipenem, PTZ = Piperacillin-Tazobactum, S = Susceptible, R = Resistant. This table shows Pseudomonas aeruginosa was highly sensitive to Imipenem (male 100%, female 93%) followed by Piperacillin- Tazobactum (male 87.5%, female 85.7%). Organisms were sensitive to Ciprofloxacin to some extent among first line drugs. (Table 3) Medworld asia Dedicated for quality research Table 4: Antimicrobial Sensitivity Pattern of MRSA in Male and Female s 109

5 AMA PEN SXT G E CIP CD VAN MRSA(n=12) Male Female (n=6) (n=6) Sensitivity NO % NO % S R S R S R AMA = Antimicrobial agent, PEN = Penicillin, SXT= Cotrimoxazole, G = Gentamicin, E = Erythromycin, CIP = Ciprofloxacin, CD = Clindamycin, VAN = Vancomycin, S = Susceptible, R = Resistant. Antimicrobial Sensitivity Pattern of Staphylococcus aureus isolated from burn wound is shown (Table 4). Staphylococcus aureus were 100% resistant to penicillin, Cotrimoxazole, Gentamicin, Erythromycin while they were 100% sensitive to Vancomycin followed by Clindamycin (33.3%). Indian J of Basic & Applied Medical Research Now with IC Value 5.49 (Revised value for 2013) 110

6 TABLE 5: Time Related Changes in organism isolated Patient No. 1 st sample 2 nd sample M1 P.aeruginosa MRSA, K.pneumoniae, E. coli M2 P.aeruginosa M3 P.aeruginosa, K.pneumoniae, Citrobacter spp M4 MRSA, K.pneumoniae F1 E.coli F2 E.coli, P.aeruginosa E.coli, P.aeruginosa F3 MRSA K.pneumoniae When re-sampling was done in 6 patients who were not responding to treatment we found the change in colonizing organisms. (Table 5) Discussion Infection with multi-drug resistant organisms is an important cause of mortality in burns. These organisms have frequently been reported as the cause of nosocomial outbreaks of infection in burn units or as colonizers of the wounds of burn (3, 4) patients. In the present study, P.aeruginosa (27%) was found to be predominant pathogen followed by K.pneumoniae (16%) & MRSA (15%). This is consistent with other studies. (5, 6, 7, 8) In contrast to other studies (7, 8), Acinetobacter was not a big threat in our hospital. Fig. 1 shows the schematic representation of different burn s in Sassoon General Hospital, Pune. Here we have compared the and sensitivity pattern from male and female s. Since from these s were having almost similar sensitivity they are most likely to be hospital acquired. E. coli, Klebsiella spp. and Citrobacter spp. were highly resistance to first line drugs like Amikacin, Ceftriaxone, Cotrimoxazole, and Gentamicin while they were 100% sensitive to Imipenem and Piperacillin-Tazobactum. This is consistent with 111

7 other studies. (5, 6) Staphylococcus aureus were 100% resistant to Penicillin, Cotrimoxazole, Gentamicin, and Erythromycin. These were found to be 100% sensitive to Vancomycin. This is consistent with other study. (5) In this study, we have found that both gram positive and gram negative show widespread resistance to first-line antibiotics. While they are relatively sensitive to second line agents which are considered as reserved drugs. This could be due to indiscriminate use of first line antibiotics leading to selective pressure in population of bacteria.re-sampling showed changes in bacterial flora in patient s burn wound. This necessitates periodic sampling of the wound sample over the hospital stay. Conclusion This study would be helpful for the determination of antimicrobial policy of hospital. Microbiological surveillance should be the ongoing process to determine change in colonizing bacteria. Based on the study we recommend the following: Every institution having burns unit should periodically to determine predominant flora causing burn wound colonization and their antimicrobial susceptibility pattern. This would help in administration of proper empirical antimicrobial treatment before microbial culture reports become available. Due to high isolation rates of microorganisms and high antimicrobial resistance it is crucial to improve infection control practices like hand washing, barrier nursing, isolation of infected persons, and culture & sensitivity for the wound of the patients not responding to empirical treatment. References: 1. Vindenes H, Bjerknes R. Microbial colonization of large wounds Burns 1995; 21: Pruitt Jr. BA, McManus AT, Kim SH, Goodwin CW. Burn Wound infections: current Status. World J Surg 1998; 22: Karlowsky JA, Jones ME, Draghi DC, Thornsberry C, Sahm DF, Volturo GA. Prevalence and antimicrobial susceptibilities of bacteria isolated from blood cultures of hospitalized patients in the United States in Ann Clin Microbiol Antimicrob 2004; 3: Agnihotri N, Gupta V, Joshi RM. Aerobic bacterial from burn wound infections and their antibiograms-a five year study. Burns 2004; 30: Singh NP, Goyal R, Manchanda V, Das S, Kaur Z, Talwar V. Changing Trends in bacteriology of burns in the burns units, Delhi, India. Burns 2003; 29: Taneja N, Emmanuel R, Chari PS, Sharma M. A prospective study of hospital-acquired infections in burn patients at a tertiary care referral centre in north India. Burn 2004; 30: Ozumba UC, Jiburum BC. Bacteriology of Burn Wounds in Enugu, Nigeria. Burns 2000; 26: Rastegar A, Alaghehbandan R, Akhlaghi L. Burn wound infection and antimicrobial resistance in Tehran, Iran: An increasing problem. Ann Burn Fire Disasters 2005; 18: Tekin R, Dal T, Bozkurt F, Deveci O, Palanc Y, Arslan E, Selçuk CT, Hoşoğlu S. Risk factors for nosocomial burn wound infection caused by multidrug resistant Acinetobacter baumannii. J Burn Care Res Jan-Feb; 35 (1):e Sahly H, Aucken H, Benedí VJ, et al. Increased serum resistance in Klebsiella pneumonia strains producing extendedspectrum beta-lactamases. Antimicrob Agents Chemother 2004; 48:

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