MICROBIAL CHARACTERISATION OF PUS ISOLATES AND THE CHANGING TRENDS IN THEIR SENSITIVITY PATTERN AT A TERTIARY CARE HOSPITAL IN KANPUR CITY R.Sujatha 1, Ankita Tripathi 2, Vineet, 2 Nidhi Pal 3 1. Professor & Head, Department of Microbiology, Rama Medical college Hospital & research center, Kanpur 2. PG, Department of Microbiology, Rama Medical college Hospital & research center, Kanpur 3. Ph.D. Scholar, Department of Microbiology, Rama Medical college Hospital & research center, Kanpur ABSTRACT: Suppurative lesions of skin,soft tissue and wound infections are an important cause of morbidity and mortality among hospitalised patients. Continuous monitoring of the bacteriological profile of the pus samples and the changing trends of their sensitivity to the antimicrobial drugs is very essential. Aims and Objectives: To study the commonly isolated organisms from pus samples and their antibiotic susceptibility pattern. Material and Methods: Study was conducted at Rama Medical College Hospital and Research Centre, Kanpur from June 2015 to Aug 2016. Pus samples from various departments of both in and out patients were collected and processed as per the standard microbiological procedures. Results: Out of the total 200 samples,146(73%) showed growth of pathogenic microorganism.136 samples showed pure growth and rest showed mixed growth of two organisms. Staphylococcus aureus was the most common organism (35%) and 1.2% were methicilline resistant strains, followed by Klebsiella spp (21%). Majority of isolates were highly resistant to most of the commonly prescribed antimicrobial drugs but vancomycin, linezolid were showed better sensitivity for gram positive cocci whereas gram negative bacilli were sensitive to imipenem, piperacillin tazobactum, colistin, polymixin-b. Conclusion: Staphylococcus aureus continues to be the dominant isolate from pus samples. High degree of resistance was seen among the bacterial isolates which pose a great challenge in treating pyogenic infections. Key words: bacterial isolates, Antimicrobial sensitivity INTRODUCTION: Infections associated with pus formation are known as pyogenic infections. [1] Pus which is a yellowish (green) or white opaque somewhat viscid matter composed of dead leukocytes, cellular debris and necrotic tissue [2] These infections can be endogenous or exogenous.the bacteria enter the body after breakdown of first line of defence-skin and seed an infective lesion. [3] This induces an inflammatory response as a result neutrophils, macrophages and other phagocytic cells invade the site of infection. This is accompanied by liquefactive necrosis and release of pus. [4] A wide variety of aerobic and anerobic bacteria may be responsible for pyogenic infection either 1
singly or in combination. [5] Antibacterial agents are among the most commonly prescribed drugs worldwide.however their indiscriminate use drives up the cost of health care and fosters the emergence of bacterial resistance rendering previously valuable drugs useless. [6] Drug resistant pathogens are a major public health concern in recent times. [6] Though the bacterial isolates from pus culture remain more or less same,their drug sensitivity pattern varies.present study primarily focuses on the bacteriological profile and the changing trends in drugs sensitivity in our region. MATERIAL AND METHODS Pus samples were collected from in and out patients of various dept. of Rama Medical College and Hospital over a period of 15 months from June 2015 to Aug 2016.The specimens were either collected in sterile swabs or the pus was aspirated into sterile syringes and transported to the microbiology laboratory. It was inoculated simultaneously on CLED media and thioglycollate broth.the organisms were identified by biochemical reactions, Gram stain, and motility tests as applicable as per standard operative procedures. The antimicrobial susceptibility tests were done by Kirby Bauer s disk diffusion method on Mueller Hinton agar and interpreted as per Clinical Laboratory Standard Institution guidelines [7].Standard antibiotics for gram positive cocci like penicillin-g (10 mcg),erythromycin (15 mcg), oxacillin (1 mcg), vancomycin (30 mcg),linezolid (10 mcg),sparfloxacin(5mcg), azithromycin(15 mcg),tetracyclin(30 mcg), teicoplanin(30 mcg), cefoxitin(30 mcg), tobramycin (10 mcg), ciprofloxacin (5 mcg), co-trimoxazole (1.25/23.75 mcg), gentamicin (10 mcg), amikacin (30 mcg), and netilmycin(30 mcg) for gram positive bacteria.for gram negative bacteria levofloxacin(5mcg),ofloxacin(5 mcg), imipenem (10mcg), meropenam (10 mcg),piperacillin(30 mcg), piperacillin /tazobactum(30/6mcg), ampicillin/sulbactum (10/10mcg),colistin(10mcg), polymixinb (300uts),Ticarcillin(75mcg),ampicillin(2mcg ),ceftriaxone (30mcg), cefipime (30mcg), ceftazidime (10mcg), cefotaxime(5mcg), cefoperazone/sulbactum (50/50mcg), cefipime / tazobactum (30/10mcg) were used (Himedia,Mumbai India). RESULTS A total of 200 samples were tested. Age wise distribution of patients has mentioned in table 1. out of which 146 samples showed significant growth. In this 136 samples showed pure growth where as 10 samples showed mixed growth of two 2
bacteria. Thus,a total of 156 organisms were isolated. Out of these isolates 78 were Gram positive cocci, of which 54 MSSA, 21- CONS, 2-MRSA, 1-Enterococcus.(table -2) Seventy six isolates were Gram negative bacilli in which most common isolate was Klebsiella followed by E.coli, then pseudomonas and proteus.staphylococcus aureus was the most prevalent organism overall{54}.staphylococcus aureus was highly sensitive to vancomycin(100%), linezolid (98%) and cefoxitin(98%),teicoplanin(90%) and fairly sensitive to netillmicin, oxacillin and tobramycin.(table -3)High resistant was shown to penicillin, cotrimoxazole, erythromycin.most of the gram negative bacteria show variable degree of resistance to all the generations of cephalosporins such as ceftriaxone,cefipime,cefotaxime as well to the combination drugs like cefoperazone - sulbactum and cefipime tazobactum.mostly were sensitive to carbapenems-imipenem and meropenam as well to colistin and polymixin B.(Table-4) Table 1:Age wise distribution of patients: Age groups Number Percent <10 7 4.7 10-20 27 18.4 21-30 38 26 31-40 24 16.4 41-50 26 17.8 >50 24 16.4 Table 2:Number of organisms and their percentage Organisms isolated Number (%) MSSA 54 35 CONS 18 11.6 Klebsiella spp 33 21 E.coli 19 12 Pseudomonas aeruginosa 10 6.4 Proteus spp 04 2.5 Acinetobacter spp 04 2.5 Citrobacter 04 2.5 Enterobacter spp 05 3.2 MRSA 02 1.2 Enterococcus 01 0.6 Candida spp 02 1.2 DISCUSSION Wound infections are quite common among surgical patients as well as suppurative lesion of skin and soft tissues are common among hospitalized patients. [8] The majority of patients were in the age group of 21-30 years which is 26 %,this is also the most common age group in a study conducted by Muluye et al [9].In our study most common gram positive isolate was MSSA(35%) which is also supported by the studies of M.Chouhan et al 46 % [5], Duggalet al 22.52% [10], and Mantravadi et al 37% [11].Study conducted in Gonder Hospital by Muluye et al [9] also showed similar findings.however in a studyconducted by Agnihotri et al [12] Pseudomonas was most 3
Table-3:Sensitivity pattern of gram positive cocci Antibiotic Staphylococcus auerus CONS Enterococcus Penicillin 52 48 14 86 100 0 cotrimoxazole 38 62 5 95 100 0 Gentamicin 70 30 29 71 0 100 Amikacin 83 17 66 34 0 100 Tobramycin 85 15 86 14 0 100 Erythromycin 78 22 33 67 0 100 Azithromycin 81 19 38 62 0 100 Oxacillin 91 9 42 58 100 0 Ciprofloxacin 72 28 76 24 100 0 Sparfloxacin 70 30 71 29 100 0 Linezolid 98 2 95 5 100 0 Vancomycin 100 0 90 10 100 0 Teicoplanin 89 11 62 38 0 100 Netilmicin 87 13 71 29 100 0 Cefoxitin 98 2 72 28 100 0 Table -4: Sensitivity pattern of Gram-negative bacilli Antibiotic E.coli S R Klebsiella Pseudomonas Proteus Acinetobacter Citrobacter E.aero genes S COT 42 58 33 67 20 80 25 75 0 100 0 100 80 20 GEN 74 26 45 55 50 50 50 50 25 75 25 75 60 40 AK 78 22 60 40 40 60 75 25 50 50 75 25 100 0 TOB 63 37 60 40 30 70 75 25 50 50 75 25 100 0 CIP 42 58 33 67 40 60 100 0 0 100 50 50 80 20 CTR 21 79 72 28 50 50 50 50 0 100 25 75 40 60 LE 78 22 84 16 70 30 75 25 50 50 75 25 60 40 OF 52 48 48 52 40 60 25 75 25 75 50 50 40 60 IPM 90 10 90 10 100 0 100 0 75 25 75 25 80 20 MRP 53 47 91 9 50 50 75 25 50 50 100 0 60 40 NET 74 26 60 40 50 50 50 50 75 25 25 75 60 40 A/S 58 42 42 58 70 30 75 25 25 75 25 75 40 60 CPM 21 79 36 64 20 80 40 60 0 100 0 100 0 100 PIT 63 37 67 33 90 10 100 0 25 75 75 25 100 0 CAZ 31 69 45 55 50 50 50 50 0 100 25 75 40 60 CFS 32 68 70 30 20 80 100 0 25 75 75 25 60 40 CTX 10 90 24 76 50 50 75 25 25 75 0 100 20 80 PB 84 16 57 43 100 0 25 75 100 0 100 0 80 20 CL 95 5 85 15 80 20 25 75 100 0 75 25 100 0 TCC 21 79 27 73 40 60 25 75 25 75 25 75 20 80 CPT 47 53 76 24 50 50 100 0 75 25 50 50 60 40 R- 4
common followed by Staphylococcus aureus.among Gram negative isolates Klebsiella sp.(21%) was most common in our study followed by E.coli(12%). In previous studies by Duggal et al [10] Pseudomonas was the most common isolate overall- 29% and E.coli (21%)was most common followed by Klebsiella(17%) in the study bymantavadi et al [11]. In our study 35% S. aureus was isolated which is in accordance with various study across India,but it is less than study conducted by Muluye et al [9] who got 65 % staphyloccus aureus. In our study S.aureus showed 100% sensitivity to vancomycin and 98% to linezolid,low sensitivity was seen in case of penicillin (52%),erythromycin(79%) which is in accordance with the studies conducted by Mantravadi et al [11] and Rao et al [13], Javeed et al [14]. In our study sensitivity to oxacillin is 91% which is higher than 61.3%inMantravadi et al [11] and 73.07%in Raghav Rao et al [13]. For gram negative bacteria high level of sensitivity was noted for Polymixin and colistin and carbapenams- imipenem though increasing resistance was seen for meropenam.combination drugs such as Piperacillin tazobactum and Cefoperazonesulbactum are sensitive especially in case of proteus.increasing resistance is seen in case of gentamicin, amikacin, tobramycin, and fluroquinolones and cephalosporins.these findings are also corraborated by Duggal et al [10], Javeed et al [14], Mantravadi et al [11]. High resistance was seen in the isolates of Acinetobacter for flouroquinolones, carbapenams and cephalosporins which isalso shown by Manchanda et al. [15] Pseudomonas isolates showed high sensitivity towards imipenem(90%), PIT (90%), and PB,these findings are also supported by Chouhan et al [5], Raghav Rao et al [13]. CONCLUSION Pyogenic infections are still a leading cause of morbidity in which staphylococcus aureus continues to be a major contributor though gram negative bacilli are also not far behind. Increasing number of multidrug resistance isolates pose a great threat to mankind. Thus the clinicians need to follow strict guidelines in prescribing antimicrobial; ensure patient compliance and appropriate infection control measures.continuous monitoring of the changing trends in antibiotic sensitivity profile should be regularly done. REFERENCES 5
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