ANTIBIOTIC RESISTANCE AMONG ISOLATES FROM WOUNDS/DISCHARGES PROCESSED AT THE DEPARTMENT OF MICROBIOLOGY MAKERERE UNIVERSITY. Authors; Aheisibwe John Obi. 13/U/1717. Katende Yayiro. Bakanasa Sumayiya.
Abstract
Background:
antibiotic resistant pathogens are difficult to treat and are associated with substantially longer hospital stay, higher treatment cost, morbidity and mortality, particularly when the etiological agent is multi drug-resistant. To address the limited data in Uganda on antibiotic resistance on wound and wound discharges we present the spectrum of bacteria isolated from makerere university microbiology laboratory
Methods:
A retrospective cross sectional study was conducted from September 2011 through April 2012 involving
100 samples from wound swabs and discharges were analyzed
.
Ress:
Of the 314 enrolled patients with SSIs (mean age 29.7 ±13.14 years), 239 (76.1%) were female. More than
half of the patients were from obstetrics and gynecology (62.1%, 195/314). Of 314 wound swabs taken, 68.8%
(216/314) were culture positive aerobically, yielding 304 bacterial isolates; of which 23.7% (72/304) were
Escherichia
coli
and 21.1% (64/304) were
Staphylococcus aureus
. More than three quarters of Enterobacteriaceae were found to
be extended spectrum beta lactamase (ESBL) producers and 37.5% of
- aureus
were Methicillin resistant
- aureus
(MRSA). MDR occurred in 78.3% (238/304) of the isolates; these were more among Gram-negative bacteria (78.6%,
187/238) compared to Gram-positive bacteria (21.4%, 51/238), (p-value < 0.0001,
χ
2 = 49.219)
.
Amikacin and
imepenem for ESBL-producing Enterobacteriacea and vancomycin for MRSA showed excellent performance except
that they remain expensive drugs in Uganda.
Conclusion:
Most SSIs at Mulago National Hospital are due to MDR bacteria. Isolation of MRSA and ESBL-producing
Enterobacteriaceae in higher proportions than previously reported calls for laboratory guided SSIs- therapy and
strengthening of infection control surveillance in this setting.
Keywords:
Antimicrobial resistance, Surgical patients, Ugand
Introduction
A wound is defined as an injury to living tissue caused by a cut, blow, or other impact, typically one in which the skin is cut or broken or it specifically refers to a sharp injury which damages the dermis of the skin. (Wikipedea the free encyclopedia).whereas,discharges are defined as the leakage of watery fluid that can be yellowish or blood stained that drains during the process 0f healing
In microbiology, the term isolation refers to the separation of a strain from a natural, mixed population of living microbes, as present in the environment, for example in water or soil flora, or from living beings with skin flora, oral flora or gut flora, in order to identify the microbe(s) of interest. (Wikipedea the free encyclopedia). This proposal will be looking at the isolates from wounds/discharges.
The common organisms isolated in the wound discharges include psuedommonas aeruginosa,streptococcus pyogens ,enterococci and staphylococcus aerus
Antibiotic resistance is the ability of the microorganism to withstand the effects of the drug; orgarnisms resistance may come about in any of the various ways enzymatic degradation of antibacterial drugs ,alteration of target proteins or changes in memberane permeability.resisitant microbes are increasingly hard to treat ,requiring alternative medication or high doses which may be costly and toxic (AriasCA,murray BE(2009) Antibiotic resistance bug in the 21 century)
Antibiotic resistance is resistance of common bacteria that cause infections to an antibacterial drug that was originally effective for treatment of infections caused by it. (www.who.int.2015). Infectious diseases still remain an important cause of morbidity and mortality among humans,especially in developing countries. Various species of bacteria live on human skin, gastrointestinal tract, in the nasopharynx and other parts of the body with less potential for causing disease because of first line defense within the body. Skin abrasion due to surgical procedure, trauma, burns, diseases, nutrition and other factors affect this first line of defense and leads to microbial contamination results infections.(Muluye et al. BMC Research Notes 2014, 7:619 http://www.biomedcentral.com/1756-0500/7/619)
There is an alarming increase of infections caused by antibiotic-resistant bacteria. Lack of uniform antibiotic policy and indiscriminate use of antibiotics may have lead to emergence of resistant bacterial strains.(JPharmacol pharmacother.2011 jul-sep)
Another form of nosocomial infection are the surgical site infections (ISSs) are the infections involving skin,subcutaneous tissue and organs/spaces opened or manipulated during an operation,occurring with in 30 days after the procedure or within one year if an orthopedic implant is in situ. The most predominant bacteria in hospital acquired ISSs are Staphylococcus aureas, Enterococcus ssp, pseudomonas aurogenosa, Escherichia coli, and other Enterobacteriaceae. In Uganda, about 10% of the surgical procedures become septic accounting for an increasing morbidity and mortality, with the commonest organism isolated being S.aureus. (Seni et al. BMC Research Notes 2013, 6:298 http://www.biomedcentral.com/1756-0500/6/298)
Problem statement
New resistance mechanisms emerge and spread globally threatening our ability to treat common infectious diseases, resulting in death and disability of individuals who until recently could continue a normal course of life. Without effective anti-infective treatment, many standard medical treatments will fail or turn into very high risk procedures. Infections caused by resistant microorganisms often fail to respond to standard treatment, resulting in prolonged illness, higher health expenditures, and a greater risk of death. (www.who.int. 2015)
RESEARCH QUESTIONS.
- What are the various bacteria found in wounds/discharges?
- What are the antibiotic resistance patterns among the various bacteria isolated from wounds/discharges?
- Are the antibiotic resistance patterns for isolates in wounds/discharges from outpatient different from those present in inpatient?
GENERAL OBJECTIVE.
- To determine the causative pathogens present in wounds/discharges, their patterns of antibiotic resistance and compare the antibiotic resistance patterns among the isolates from outpatient and inpatient records.
SPECIFIC OBJECTIVES
- To determine the major pathogens present in wounds/discharge cultures.
- To determine the antibiotic resistance patterns among isolates from wounds/discharge cultures.
- To compare the antibiotic resistance patterns among the isolates from wounds/discharge cultures from outpatient and inpatient
LITERATURE REVIEW –
The centers for Disease Control and Prevention (CDC) report re-grading healthcare associated infection indicated that antimicrobial-resistant gram-negative bacilli are an emerging threat in the healthcare setting [6].The study conducted on MDR among gram-negative pathogens that caused healthcare-associated infections in Atlanta, Georgia (USA) evaluated that 10% of aeruginosa and 15% K. Pneumonia found to be both resistant to3 antimicrobial class. A much larger proportion, 60% of Acinetobacter isolates were resistant to at least3 antimicrobial classes. Though less common than 3-class resistance, isolates with 4-class resistance were also seen insignificant numbers and across regions [Allen AJ, Hidron AI, Patel J, Srinivasan A:Multi drug resistance among gram-negative pathogens that caused healthcare-associated infections reported to the National Healthcare Safety Network, 2006–2008.Infect-control Hosp Epidemiol2010,31(5):258–532.].
Providing effective health care, in developing countries such as Cambodia is challenged by the spread of drug resistant pathogens [van der Bij AK, Pitout JD. The role of international travel in the worldwidespread of multiresistant Enterobacteriaceae. J Antimicrob Chemother.2012;67:2090]. Emergent resistant pathogenic strains have demonstrated potential to quickly spread beyond their initial geographic point of origin [Dong J, Olano JP, McBride JW, Walker DH. Emerging pathogens: challenges and successes of molecular diagnostics. J Mol Diagn. 2008;10:185]. Welldocumented examples include the spread specification-resistant S. aureus(MRSA) clones around the world capable of out competing pr-existing local populations [rundmann H, Aanensen DM, van den Wijngaard CC, Spratt BG, HarmsenD, Friedrich AW. Geographic distribution oStaphylococcus aureuscausinginvasive infections in Europe: a molecular-epidemiological analysis. PLoS]; the emergence of
Enterobacteriaceaewith resistance to carbapenems conferred by New Delhimetallo-β-lactamase 1 (NDM-1) from India and Pakistan
[Lascols C, Hackel M, Marshall SH, Hujer AM, Bouchillon S, Badal R, et al.Increasing prevalence and dissemination of NDM-1 metallo-β-lactamase inIndia: data from the SMART study (2009). J Antimicrob Chemother]; and the global spread of multidrug resistantAcineto-bacterspecies . Another factor that fuels antibiotic re-
sistance in Cambodia is the unregulated access toantibiotics. In addition, the quality of antibiotics is notwell regulated with a significant presence of counterfeitdrugs on the market [ Sokheng V. 200 kilos of counterfeitmeds seized in Capitol. The Phnom PenhPost, 2013 June 13. [cited 2013 Jul 29]. http://www.phnompenhpost.com/national/200-kilos-counterfeit-meds-seized-capital.].
Data on antibiotic drug resistance amongst clinical sig-nificant bacteria in Cambodia is limited to date. The signifi-cance of the development of drug resistant motifs wasevidenced in an investigation of the prevalence of CTX-Mbeta-lactamase enzymes inE. colicausing community acquired urinary tract infections . Another study reportedon the first documented cases ofcommunity acquiredMethicillin ResistantS. aureus(MRSA) infections inCambodia. In thiswork, seventeen children were found to have community acquired MRSA infections. All cases were caused by two independent MRSA clones identified by mo-lecular characterization [1 A recent large study into bacterial causes of blood stream infections at a communityhospital in Phnom Penh from 2007–2010 demonstrated high level antibiotic resistance patterns to include an observed 62.3 % resistance ofE. coliisolates to ciprofloxacin,90 % ofSalmonella typhi
isolates having decreased susceptibility to ciprofloxacin, and 21.7 % of S. aureusisolates be-
ing resistance to methicillin [lieghe ER, Phe T, DeSmet B, Veng HC, Kham C, Lim K, et al. BloodstreamInfection among adults in Phnom Penh, Cambodia: key pathogens and resistance patterns. PLoS One. 2013;8(3):e)
The introduction of antibiotics has reduced mortality rates which were on the high side due to life threatening diseases, especially infections. Enlightenment on the use and management of antibiotics cannot be overemphasized as it will continue to be the way out of many infections which occur frequently in plants and animals including humans. Increase in the misuse and mismanagement of antibiotics which are now leading to drug resistance is creating a lot of concern in medical practice. The current spread of multi drug resistant bacterial pathogens has added a new dimension to the problem of wound infections [Sule AM, Olusanya O. Invitro antimicrobial activities of fluoroquinolones comparedwith common antimicrobial agents against clinical bacterial solates from parts of South Western Nigeria. Quarterly J Hospital Med 2000; 10 (1): 1821.2].
This is particularly worse in resource poor countries where sale of antibiotics is poorly controlled . Infection of wound is the successful invasion, proliferation by one or more species of microorganisms anywhere within the body’s sterile tissues, sometimes resulting in pus formation. Development of wound infection depends on the interplay of many factors. Wound infections may occur following accidental trauma and injections, but postoperative wound infections in hospital are most common. Some infections are endogenous in which infection (. Cheesbrough M. Microbiological tests. In: District laboratory practice in tropical countries. 2nd ed. U.K: Cambridge University Press; 2006; p 189.8. Paul SB, Roy RL, Ghosh AC. Multiple Antibiotic Resistance (MAR) index and its reversion in Pseudomonas aeruginosa. Letters in AppliedMicrobiol 1997; 24: 1)tion
The term multidrug-resistant (MDR) applies to a bacterium that is simultaneously resistant to a number of anti-microbial drugs belonging to different chemical classesor subclasses through various mechanisms [.Magiorakos AP, Srinivasan A, Carey RB,et alMultidrug-resistant,
extensively drug-resistant and pandrug-resistant bacteria: aninternational expert proposal for interim standard definitions foracquired resistance.Clin Microbiol Infect2012 18:]
One of the methods used by many authors and authorities to characterize organisms as MDR is based on the results of invitro antimicrobial susceptibility test. Antimicrobial drug resistance can be acquired as a result of mutation or acquisition of resistance genes via horizontal gene
transfer, or can be an innate feature of an organism that’s encoded chromosomal [2].MDR in both the hospital and community environment are important concern to the clinician, patients and the pharmaceutical industries [3]. The widespread uses of an-antibiotics, together with the length of time over which the drugs have been available at market have led to major problems of the emergence of resistant organisms
A study conducted in one of the tertiary hospitals in Ethiopia also reported that about 51% of
the gram negative bacterial isolates from open wounds
were identified as MDR .Such increase in both community and hospital-acquired antimicrobial-resistant bacteria is challenging the ability of effective patient treatment, prudent infection control and new treatment alternatives. According to Olayinkaet al.,constant bacteriological monitoring of the pathogens isolated from clinical specimens of patients in special units is to draw attention of clinicians and infection control specialists to their current antibiotic susceptibility pattern and how often specific pathogens are isolated (.Zeleke WT:Multiple antimicrobial resistance in bacterial isolates from clinical and environmental sources of Jimma Hospital. Ethiop J scien2002,25:295–302.)
3.0 Methodology
3.1 Study Design
This study will be retrospective the cross section study
3.2Research approach
The data on cultures of wound isolates/ discharge and their drug sensitivity pattern received at makerere university clinical laboratory will be analyzed by quantitative means
3.3 Study Area
Wound /discharges samples received at Makerere university clinical microbiology laboratory
3.4 Study Population
The study population will be date on antibiotic resistance among isolates from wound and wound discharges processed at the makerere university clinical microbiology laboratory.
Eligibility Criteria
3.4.1 Inclusion criteria
Data on antibiotic resistance among isolates from wound and wound discharges processed at the makerere university clinical laboratory.
3.4.2 Exclusion criteria
Date on fungi positive cultures
Incomplete data
Data on isolates that is sensitive
3.5. Sampling strategy
Consecutive sampling method will be used. 100 samples will be selected from samples of wound/discharges
3.6. Data collection method, instruments and procedure
Data will be collected from the clinical microbiology laboratory data base and the data collection tool to be used will be excel work sheet.
3.7. Data analysis.d wound discharge sample from September, 2010 to August, 2013. Socio-demographic and wound discharge sample during the study period will be the participants.Data will be analyzed using SPSS version 20 software. P-value ≤ 0.05 was considered statistically significant
Significance of the study; antibiotic resistance is a major cause of serious infections causing an economic budden ,mortality and morbidity.(WHO)
