Irrational use of antimicrobial agents often

Antibiotic Resistance of Isolated Bacteria in 1 and Abdo-Rabbo A. 2 Irrational use of antimicrobial agents often leads to the multi-drug resistance microorganisms. This study is aimed at investigating the prevalence of microbial resistance to different antibiotics in Ibn Sina General Teaching Hospital in Al-Mukalla, Yemen during the period from January to December 2001. Susceptibility among the isolated bacteria to the used antibiotics for sensitivity test during this study was investigated. 398 specimens were collected from male and female patients. 132 of them were positive bacterial cultures (96 Gramnegative bacteria and 36 Gram-positive and tested for susceptibility to 16 different antibiotics. The most common isolated bacteria Abstract found were E. coli and Staphylococcus aureus, and mostly from urine and swabs samples. This study reveals that the isolated bacteria are more susceptible to cefotaxime, with inhibiting activity between 80-100% of strains. The most commonly used and Essential Drugs List, namely co-trimoxazole, cloxacillin and tetracycline (doxycycline) have the least antimicrobial activity against the isolated bacteria. Irrational use of antibiotics could be behind the high rate of drug resistance for some antibiotics. Therefore monitoring of antimicrobial susceptibility in different regions of Hadhramout in particular and Yemen in general is very important. 1 2 ALL.indd 77 12/04/2007 06:19:46 ã

78 Resistance to antibiotics refers to unresponsiveness of microorganisms to antibiotics. Antibiotic resistance has become a serious problem in disease treatment. Today, after almost half a century of widespread use for penicillin, more than 90% of all isolates are resistant (1). As a result, penicillin can no longer be relied upon to treat infections caused by many organisms despite its safety and reasonable price. In 1998 it was reported that there was an overuse and misuse of antibiotics in Yemen. The results of this report revealed that 58% of the collected prescriptions contain antibiotics and 37% of all prescribed drugs were antibiotics (2). Over-prescribing is often due to an imprecise diagnosis & worker, combined with a desire to please the patient. Widespread use of antimicrobial agents often leads to the development of multi-drug resistant microorganisms (3). Acquired or emerging bacterial resistance to one or several antimicrobial agents is a global problem (4,5). Early evidence of the importance of antimicrobial resistance came from studies during Shigella dysenteriae outbreaks in the 1950 in Japan (6). Increasing resistance INTRODUCTION to tetracycline, chloramphenicol, and sulphonamides was apparent and laboratory studies show that this resistance was transferable to other bacteria (7). By the time of these outbreaks, molecular techniques had advanced to enable the genetic basis of antimicrobial resistance to be determined (8). The prevalence of resistance to antibiotics varies from species to species and from country to country (9). As the pattern of bacterial resistance is constantly changing, monitoring of antimicrobial susceptibilities is important. Such studies provide information on the pathogenic organisms isolated from patients, and assist in choosing the most appropriate empirical antimicrobial therapy (3). This study is designed to identify the type of the sample containing the highest number of bacteria and the common bacteria isolated from different specimens examined at Ibn Sina General Teaching Hospital (ISGTH), Al-Mukalla, Hadhramout Governorate, Yemen as well as their distribution among male and female patients. It also aims at the analysis of the antimicrobial resistance pattern of the isolated bacteria. ALL.indd 78 12/04/2007 06:19:46 ã

This study was carried out on all bacterial isolates recovered from urine, swabs (wound, ear, eye, tonsil swabs), semen, and vaginal discharge, collected from both male and female patients and tested at the microbiological laboratory of ISGTH during the period from January to December 2001. A total number of 398 specimens were collected. 252 specimens (63%) were from male and 146 (37%) specimens from female, as shown in (Table 1). The routine culture work for all types of specimens was performed as described in Cowan and Steel (10). Materials and Methods The types of bacteria and their distribution among male and female patients as well as the type of the samples calculated. The antibiotic sensitivity testing From the total specimens (398) tested, only 140 (35.2%) positive cultures Results was performed using the Kirby-Bauer disc diffusion method (11). The media used was Muller-Himton agar (Oxoid) or Nutreint agar. The antibiotic contents of the multidiscs were Ampicillin/Sulbactam (AS, 20 µg), Co-trimoxazole (BA, 25µg), Cephalexin (PR, 30 µg), Tetracycline (TE, 30 µg), Cefotaxime (CF, 30 (OF, 5 µg), Cloxacillin (CX, 1 µg), Roxythromycin (RF, 15 µg), Lincomycin (LM, 2 µg), and Gentamicin (GM, 10 µg) used for sensitivity testing of Grampositive bacteria. The antibiotic contents of multidiscs used for Gram-negative bacteria were Piperacillin (PC, 100 µg), Chloramphenicol (CH, 30 µg), Ceftizoxime (CI, 30 µg), and Amikacin (AK, 30 µg) in addition to AS, BA, CF, CP, TE, OF, GM, and PF with same concentration as above. according to sex, a total of 36 (58% in male and 42% in female) and 96 (61% in male 60% and 40% of these positive cultures were for male patients and female patients respectively (Table 2). Regarding the distribution of Grampositive and Gram-negative bacteria isolates were Gram-positive and Gramnegative respectively (Table 3). Therefore the most isolated bacteria were the Gramnegative type. The other 8 positive cultures were fungi, which were not considered in 79 ALL.indd 79 12/04/2007 06:19:47 ã

80 the sensitivity testing. The highest percentage of bacteria was isolated from urine samples (56.3% and 57.7%) of the isolated bacteria among male and female patients respectively. The common bacteria isolated from all studied cultures among male and female patients were E. coli, Pseudomonas aurogenosa, Klebsiella spp., Protues spp., Neisseria gonorrhoae, and Stapylococcus aureus. E. coli represented the highest value (23.8% and 50.0%) of the isolated bacteria among male and female patients respectively, followed by Stapylococcus aureus (26.3% and 28.8%) among male and female patients respectively (Table 4 and 5). The susceptibility of bacterial isolates It is a matter of fact that susceptible bacteria die, leaving only antibiotics resistant survivors, which multiply to increase the prevalence of resistant forms (1). Bacteria become resistant to antibiotics by several mechanisms, such as production of an enzyme that destroys the antibiotics or a croup in the structure of the target site of the antibiotics (12). Bacterial resistance to the treatment of infectious diseases, leading not only to treatment failures but also to increased costs. Infections caused by resistant bacteria are more likely to cause prolonged illness, Discussion to different antimicrobial agents used in the sensitivity testing differs according to the type of antibiotic used. The majority of isolates were susceptible to cefotaxime, and amikacin. For example E. coli was susceptible to above-mentioned antibiotics with percentage of 89, 98, 100, 89, and 100 respectively, whereas Neisseria gonorrohoa was sensitive to all those antibiotics gentamicin) except amikacin (Table 6). Regarding the Gram-positive bacteria represented by Staphylococcus aureus, the highest susceptibility was found in cephalexin, cefotaxime, roxythromycin, lincomycin, and gentamicin, with percentage of 94, 92, 94, 86, and 100 respectively (Table6). frequent and prolonged hospitalization and a higher death rate (13). As a result of antibiotic resistance, the world is coped with the problem of producing more powerful antibiotics to treat infections but at the same time it is full of risk and hike in price. (14). Before discussing the results obtained in this study it is worth to mention that most patients, especially outpatients are treated empirically (3, 10), and therefore neither the organisms implicated nor their antimicrobial susceptibilities are even known. E. coli was the most frequently isolated bacteria. This could be due to the fact they are widely ALL.indd 80 12/04/2007 06:19:48 ã

spread from person to person. The other predominant bacteria isolated in this study were Staphylococcus aureus, Klebsiella spp., and Proteus spp. are known to be associated with hospital infections (15). All of which are either naturally resistant to antimicrobial agents or capable of acquiring resistance by various mechanisms (16). E. coli is least susceptible (2%, 7%, tetracycline respectively. This is probably due to widespread and long-term use of these antibiotics. Another commonly used antibiotic namely ampicillin was resisted by 86% of E. coli isolates (17). It is well known that widespread and long-term use of a particular antibiotic e.g ampicillin causes the higher prevalence of resistant forms (18). The increased frequency and spread of resistant bacterial strains also are the consequences of the inappropriate use of antibiotics. A recent study in Mukalla has shown a correlation between the occurance of multiresistant bacteria and antibiotic consumption patterns (19). In this study 82% of isolates of E.coli were sensitive to ampicillin + sulbactam because the later is beta-lactamase inhibitor so, enhances the antibacterial activity of ampicillin. In our study most of the isolated Gram-negative bacteria showed resistance of Pseudomonas aurogenosa was resistant that bacterial isolates have developed less resistance to third generation cephalosporins, cefotaxime, and ceftazidime. This is why the new antibiotics are often ignored for prescription. It has been shown that resistance was associated with prior use of cefotaxime, ceftazidime, and piperacillin (20). This was (21), who showed that previous administration of third generation cephalosporins could be associated with infection by multi-resistant Enterobacter spp. Cross infection is contributed to the spread of multi-resistance bacterial clusters in the hospitalized patients. Several identical antibiotic sensitivity patterns, which strongly suggest the possibility of cross infection as an additional factor to the spread of resistance. The problem of increasing antibiotic resistance is becoming serious worldwide (22). Hence, antimicrobial surveillance program is to be made effective at the local level and at the national level. The resistance among the isolated strains could be attributed to several mechanisms mostly related to misuse of antibiotics. Thus, the knowledge of sensitivity patterns of antibiotics is very important as in most of the cases antibiotics may be selected for bacterial infections that are resistant to these antibiotics. The high prevalence of antibiotic resistance found in this study is probably due to lack of effective antibiotic regulations, lack of an appropriately trained health workers, and lack of proper information and 81 ALL.indd 81 12/04/2007 06:19:49 ã

self-medication with antibiotics. It is also prevalent because of patient s demand, and pressure of the pharmaceutical industry. All these are the main reasons for irrational use of antibiotics, which consequently lead to antibiotic resistance. In the light of the results obtained in this study, it is obvious that the prevalence of antibiotic resistance is too high and it may lead to serious health risks and needless expenditures. Hence,there is a great need for rational use of antibiotics in this region and the country. In order to delay the emergence of resistant microorganisms, the possible control measures might be taken into consideration: 1. It is very important to identify the resistant and sensitive microorganisms for choosing the appropriate antibiotic than prescribing randomly. 2. Antibiotics should be prescribed only when they are inevitable and medicine should be considered in Conclusion relation to the risk involved, and appropriately used. 3. Antibiotics should not be used for viral infection, routinely for noninfections, trivial or non-severe cases. 4. Infection by organisms notorious for developing resistance must be treated intensively. 5. Antibiotic combination should be purpose and not blindly. 6. hygenic situation is essential to limit the spread of hospital organisms. 7. Monitoring of antibacterial susceptibilities in different regions of Hadhramout is very important probably by implementing antiantibiotic policy. 82 ALL.indd 82 12/04/2007 06:19:50 ã

Table 1: Total number of specimens used for culture and antibiotic sensitivity testing Sex Culture No. % Male 252 63 Female 146 37 Total 398 100 Table 2: Sex Positive culture Negative culture No. % No. % Male 84 60 168 65.1 Female 56 40 90 34.9 Total 140 100 258 100 Table 3: Sex Gram-positive bacteria Gram-negative bacteria No. % No. % Male 21 58 59 61 Female 15 42 37 39 Total* 36 100 96 100 *In the 140 cultures there were 8 fungal cultures, which excluded 83 ALL.indd 83 12/04/2007 06:19:51 ã

Table 4: Bacteria Sample Total E. Staphylococcus Klebsiella Pseudomonas Proteus Neisseria coli aureus spp. aurogenosa spp. gonorrhoae Urine 45 16 8 12 7 2 0 Swabs 27 0 12 2 10 2 1 Semen 4 3 1 0 0 0 0 Ear 4 0 0 0 4 0 0 80 19 21 14 21 4 1 % 100 23.8 26.3 17.5 26.3 5.0 1.3 Table 5: Bacteria Sample Total E. coli Staphylococcus aureus Klebsiella spp. Pseudomonas aurogenosa Proteus spp. Neisseria gonorrhoae Urine 30 19 10 0 1 0 0 Swabs 7 0 3 0 3 1 0 Vaginal discharge 11 7 2 0 0 0 2 Ear 4 0 0 0 3 1 0 Total No. % 52 26 15 0 7 2 2 100 50.0 28.8 0 13.5 3.8 3.8 84 ALL.indd 84 12/04/2007 06:19:52 ã

Table 6: antibiotics Gram-negative bacteria E. coli Pseudomonas aurogenosa Klebsiella spp. Protues spp. Neisseria gonorrhoae Total samples AS BA CF PC CH CP CI TE OF GM AK PF 45 37 3 40 39 42 44 45 15 42 40 45 1 % 82 7 89 87 93 98 100 33 93 89 100 2 28 4 1 26 28 26 28 0 3 8 26 28 20 % 14 4 93 100 93 100 0 11 29 93 100 71 14 10 3 12 13 13 11 12 12 11 14 14 0 % 71 21 86 93 93 79 86 86 79 100 100 0 6 3 0 6 6 6 1 5 0 1 6 6 0 % 50 0 100 100 100 17 83 0 17 100 100 0 3 0 0 3 0 0 3 3 3 0 3 0 0 % 0 0 100 0 0 100 100 100 0 100 0 0 Total number 96 54 7 87 86 87 87 65 33 62 89 93 21 Gram-positive bacteria Total samples AS BA PR TE CF CP PF OF CX RF LM GM Stapylococcus aureus 36 16 2 34 0 33 4 4 7 22 34 31 36 % 44 6 94 0 92 11 11 19 61 94 86 100 Total number 36 15 2 33 0 32 4 4 6 21 33 30 35 AS = Ampicillin/Sulbactam (20 (30 (5 PR = Cephalexin (30 = Roxythromycin (15 LM = Lincomycin (2 µg) 85 ALL.indd 85 12/04/2007 06:19:53 ã

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