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Prevalence of methicillin resistant Staphylococcus aureus, multidrug resistant and extended spectrum β-lactamase producing gram negative bacilli causing wound infections at a tertiary care hospital of Nepal

Prevalence of methicillin resistant Staphylococcus aureus, multidrug resistant and extended... Background: Treatment and prevention of wound infection continues to be a challenging issue in clinical settings of Nepal especially in the context of globally growing problem of antimicrobial resistance. Study on opportunistic pathogens and sensitivity to commonly prescribed local antimicrobial agents are cardinal to reduce the disease burden of wound infections. The aim of this study was to determine the prevalence and antimicrobial susceptibility pattern of methicillin resistant Staphylococcus aureus (MRSA) and extended spectrum β-lactamase (ESBL) producing bacteria from wound infections of patients at a tertiary care hospital in Nepal. Methods: Pus specimens were processed using standard microbiological procedures. Antimicrobial susceptibility test was performed following the modified Kirby Bauer disc diffusion technique. Clinical information of patients was obtained from preformed questionnaire and hospital record. Results: One hundred eighty two pus specimens from wounds of different body parts: leg, hand, backside, abdominal part, foot, breast and chest, head and neck region were collected and analyzed; 113 bacterial isolates were isolated showing the overall bacterial growth rate of 62%, where the highest rate was among patients of ≤10 years age group (82.1%). A higher rate (68.5%) of bacterial isolates were from inpatients (p < 0.05). Among 116 bacterial isolates, Staphylococcus aureus was the most predominant bacteria (56.9%) followed by Escherichia coli (8.6%), coagulase negative staphylococci (7.8%), Acinetobacter spp. (5.2%), Klebsiella pneumoniae (5.2%), Pseudomonas aeruginosa (4.3%), Enterococcus spp. (4.3%), Citrobacter freundii (2.6%), Proteus vulgaris (1.6%) and P. mirabilis (0.9%). Both Gram positive (73.3%) and negative (78.8%) isolates showed high frequency of sensitive to gentamycin. Conclusion: Among S. aureus isolates, 60.6% were MRSA strains, whereas 40% of K. pneumoniae and 33.3% of C. freundii were ESBL producing bacteria followed by E. coli (25%). It is thus paramount to address the burden of silently and speedily increasing infections caused by drug resistant strains of MRSA and ESBL in Nepal. Keywords: Wound infection, Methicillin resistant Staphylococcus aureus, ESBL, Multidrug resistant, Nepal * Correspondence: upreti.naru@gmail.com; rayamajheebinod@gmail.com Central Department of Microbiology, Tribhuvan University, Kirtipur, Nepal National College (Tribhuvan University), Khusibu, Kathmandu, Nepal Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 2 of 10 Background evidence-based treatment algorithm can control the Wound infections result after the active interactions that wound infections. takes place between a host, a potential pathogen and the surrounding extrinsic factors. The intensity of wound in- Methods fections may range from a simple self-healing to a severe Study site and population and life threatening [1]. Tissue invasion by bacterial path- A descriptive cross-sectional study was designed and ogens is determined by the location of wound [2]. The carried out to determine the bacteriological profile of common bacterial pathogens isolated from wound wound infections. MRSA, MDR and ESBL producing infections are Staphylococcus aureus, S. epidermidis, S. bacteria were identified from the pus samples of patients pyogenes, coagulase negative staphylococci (CoNS), Acine- with wound infection visiting KIST Medical College and tobacter spp., Pseudomonas spp., Escherichia coli, Klebsi- Teaching Hospital, Kathmandu, Nepal from November ella spp., Proteus spp., Enterobacter spp., Citrobacter spp., 2014 to August 2015. A total of 182 pus and Fine Needle and anaerobes such as Clostridium spp. and Peptostrepto- Aspirate specimens were collected from patients with coccus spp. [3, 4]. Acquisition of drug resistance by these clinical features of wound infection like patients with pathogenic strains has posed serious challenges for the pain, complaints of regular discharge, foul smelling and remedy and management of wound infections around the red swelling. During the study, patients of all age groups world [5]. Wound infections can be monomicrobial or and both genders from out-patients (39/182) and polymicrobial [6]. The presence of bacterial pathogens in in-patients (143/182) were included. Patients who were wound infections is not uncommon but all wounds do not admitted in the hospital for more than 3 days and/or in support the same range and number of species [7]. prior antibiotic treatment and anaerobic wound infec- Hospital-acquired wound infections are the leading cause tions were excluded from this study. of morbidity hence, proper management of wound infec- tion in clinical settings is paramount [8]. The treatment of Sampling procedure wound infections is being more challenging due to methi- Pus specimens were collected from elective surgery cillin resistant S. aureus (MRSA), involvement of polymi- wounds of hospital wards [surgical, post- operative, crobial flora and fungi [9]. In addition, antimicrobial trauma, orthopedic, ENT (eye-nose-throat), gynecology resistance (AMR) is creating a serious problem in all clin- wards], open and dressed wounds. Sterile cotton swabs ical settings and AMR has become the biggest public and fine needle syringes (FNS) were used to collect pus health threat globally [10]. samples from open wounds then each sample was la- MRSA, a leading strain of wound infections, involves beled properly with date/time of sample collection, col- significant areas of skin or deeper soft tissues like ab- lection method and the patient’s details. Swabs from scesses, cellulitis, burns or infected deep ulcers [11]. open wounds were aseptically collected after cleaned off Extended spectrum β- lactamase (ESBL) producing En- while pus from dressed wounds were collected after re- terobacteriaceae are also in frontline of wound infections. moving the dressing items. The information of each pa- In ESBL, positive strains plasmid mediated AmpC en- tient was recorded such as site of infection, signs and zymes, and carbapenem hydrolyzing β- lactamase (carba- symptoms, other underlying diseases, and prior antibi- penemases) conferred resistance to the newer β- lactam otics administration. Before collecting the sample, the antimicrobials [12]. ESBL have been reported most fre- area was rinsed with sterile normal saline and then a quently in Escherichia coli and Klebsiella spp. including sterile cotton swab was gently rolled over the surface of other bacterial species such as Salmonella enterica, P. aer- the wound. The swab with pus was kept in a sterile test uginosa,and Serratia marcescens [13]. This surge in anti- tube with cap where details was labeled properly. For microbial resistance further delays wound healing and the the collection of pus sample from deep wounds, FNS infection becomes more worst which increases hospital was used. Specimens were collected from wounds of dif- stay, prolongs trauma care, and high medical costs [14]. ferent body parts: leg, hand, back part of body, abdom- On the other hand, most of the clinical laboratories in inal part, foot region, breast and chest part, head and underdeveloped countries are not equipped with testing neck region. Amies transport medium was used to trans- facilities to detect ESBL producing bacteria. In Nepal, port the collected specimens. For Fine Needle Aspiration there is scanty data on the prevalence of ESBL-producing Cytology (FNAC), the syringe was properly capped, la- bacteria causing wound infections. The goal of this beled and dispatched to the laboratory immediately. study was to determine the prevalence of MRSA, multi- drug resistant and ESBL producing Gram negative ba- Processing of samples cilli from wound infections of patients visiting KIST Macroscopic examination of samples Medical College and Teaching Hospital, Lalitpur, Among 182 pus specimens collected, 56 (30.8%) were Nepal. Early reporting of drug resistant pathogens and from the leg region, 43 (23.6%) from hand, 15 (8.2%) Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 3 of 10 from back part of body, 14 (7.8%) from abdominal part, (5 μg), cefazolin (30 μg), ceftriaxone (30 μg), cefotaxime 15 (8.2%) from foot region, 6 (3.3%) from breast and chest (30 μg), amikacin (30 μg), piperacillin (100 μg), tobra- part, and 33 (18.1%) were from head and neck region mycin (10 μg), imipenem (10 μg), and meropenem wounds. All the specimens were visually examined for (10 μg). After 24 h of incubation period at 37 C, the zone consistency, color, turbidity, presence or absence of blood of inhibition (ZOI) was measured then the results were depending upon the type and site of wound. Additionally, analyzed according to the guidelines issued by the Clinical pus swabs were observed whether they were labeled cor- Laboratory Standard Institute (CLSI - M100-S25, 2015) rectly or not. [16]. Isolates resistant to two or more antimicrobial classes were reported as multi drug resistant (MDR) strains. Anti- Microscopic examination of samples microbials and their doses were selected based on pre- After transportation of specimens to the laboratory, Gram scription frequency by physician and availability in the staining of each specimens was performed [15]. study setting. Minimum inhibitory and bactericidal con- centration (MIC and MBC) of used antimicrobials were Culture of specimens and identification of isolated bacteria not determined due to unavailability of all antimicrobials Pus specimens were inoculated into Chocolate agar, Blood powder at the time of study period. agar, MacConkey agar, Nutrient agar and Potato Dextrose agar plates as per the clinical laboratory guidelines [16]. Screening and confirmation for ESBL producers The preliminary identification of the isolated bacteria was Enterobacteriaceae isolates were screened for possible done based on colony form, size, shape, pigmentation, ESBL producing bacteria using antibiotic discs of cefo- margin, and elevation. The isolated organisms were identi- taxime (30 μg), ceftazidime (30 μg), ceftriaxone (30 μg) fied by performing different biochemical tests and Gram and aztreonam (30 μg) [17]. According to the guidelines, staining then antimicrobial susceptibility tests were per- bacterial isolates showing ceftazidime < 22 mm, and cef- formed. In case of no growth after 24 h of incubation fur- otaxime < 27 mm are the possible ESBL producer. The ther incubation was done up to 48 h at 37 C. After proper suspected ESBL producer strains were subjected to incubation period, the culture plates were examined for double disc synergy test (DDST) for the confirmation of microbial growth. In every case, each plate was carefully ESBL producing Enterobacteriaceae [18]. observed. Then, biochemical tests were performed in ster- ile media for the identification of bacterial isolates. Identi- Statistical analysis fication of Staphylococci spp. was done by Gram staining, All data were examined using iBM SPSS version 21.0. catalase test, slide coagulase and tube coagulase test. Simi- Frequencies were calculated for categorical variables. larly, Gram negative strains were identified based on result Chi-square test was calculated to analyze significant dif- of different biochemical tests; Oxidase, Catalase, Methyl ference at 95% of confidence level, p value of < 0.05 was Red (MR), Voges Proskauer (VP), Citrate utilization, Urea considered significant, unless otherwise noted. Hydrolysis, Triple Sugar Iron agar (TSI), Sulfide Motility and Indole test. Colony morphology and microscopic ob- Quality control servation were taken in account for identification of All prepared biochemical and streaking media were Candida spp. checked for their sterility. Strains of E. coli ATCC 25922 and S. aureus ATCC 25923 were used as reference strains Examination of antimicrobial susceptibility pattern of for quality control of AST and biochemical tests. The isolated organism same strain of E. coli was also considered as a negative Antimicrobial susceptibility pattern was performed for control during the screening and phenotypic confirmation isolated and identified bacteria from pus samples follow- (DDST) tests of ESBL producing Gram-negative bacilli. ing the modified Kirby Bauer disc diffusion technique. A dilution of the identified organism was prepared compar- Results ing with the standard 0.5 McFarland turbidity which was Bacterial growth used to swab over the Mueller Hinton agar (MHA) A total of 182 samples were collected and examined medium for the antimicrobial susceptibility test (AST). from hospital patients with clinical features of wound in- Discs of antibiotic used for Gram positive bacteria were fection, 113 (62%) specimens were positive for aerobic ampicillin (10 μg), cefotaxime (30 μg), gentamycin (10 μg), bacterial growth. Out of 116 bacterial isolates obtained ciprofloxacin (5 μg), trimethoprim + sulfamethoxazole from 113 positive samples, 83 (71.6%) bacterial isolates (25 μg), cefoxitin (30 μg), amikacin (30 μg) and tetracyc- were Gram positive and 33 (28.4%) isolates were Gram line (30 μg) whereas antibiotics used for Gram negative negative. Among processed specimens, 64% (100/156) of organisms were ampicillin (10 μg), trimethoprim + sulfa- pus swabs and 50% (13/26) of aspirated pus specimens methoxazole (25 μg), gentamycin (10 μg), ciprofloxacin have shown aerobic bacterial growth (Fig. 1). Out of 113 Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 4 of 10 Fig. 1 Percentage of bacterial growth in pus swab and aspirated pus swab specimens positive for aerobic bacterial culture, polymi- Growth pattern in outpatient and inpatient departments crobial growth was observed in 3 (2.7%) specimens One hundred forty three samples were from inpatient de- where combinations of S. aureus - Acinetobacter spp., partment (from different wards) and 39 samples were S. aureus - Citrobacter freundii and Enterococcus spp. from outpatient department. Out of 143 samples from in- - Candida spp. were reported. High incidence of MRSA patient, 98 (68.5%) were positive and out of 39 samples 60.6% (40/66), MDR (80% of E. coli,68.2% of S. aureus, from outpatient, 15 (38.5%) were positive for bacterial 80% of P. aeruginosa, 77.7% of CoNS and 50% of Proteus growth. Type of patients based on department had a posi- spp.) and ESBL (25% of E. coli,40% of K. pneumoniae,and tive correlation with aerobic bacterial growth (p <0.05). 33.3% of C. freundii) producing isolates were reported in Pus specimens were collected from inpatient depart- this study. ments/wards (such as surgical wards, post- operative Sixty two (34.1%) specimens processed were collected from the leg, 36 (19.8%) from hand, 16 (8.8%) from back- Table 1 Socio-demographic features of the patients and ratio side, 15 (8.2%) from abdominal, 22 (12.1%) from foot, 13 of wound infection (7.1%) from breast and chest, 18 (9.9%) from head and Demographic Infected Not infected Total neck part. Majority of patients (86%) were presented with features [No. (%)] [No. (%)] [No. (%)] fever, lethargy and muscle pain at the time of sample col- Sex lection. None of the patients were reported with any Male 45 (55.6) 36 (44.4) 81 (44.5) underlying diseases. Patients who had other infections and Female 68 (67.3) 33 (32.7) 101 (55.5) antibiotic treatment were excluded from the study subject. Total 113 (62.1) 69 (37.9) 182 (100) Age in years Wound infection in relation with demographic characteristics ≤ 10 23 (82.1) 5 (17.9) 28 (15.4) of the patients 11–20 18 (60.0) 12 (40.0) 30 (16.5) Eighty one (44.5%) samples were from male patients and 21–30 12 (44.4) 15 (55.6) 27 (14.9) among them 45 (55.5%) samples showed aerobic bacterial 31–40 21 (65.6) 11 (34.4) 32 (17.6) growth, while 101 (55.5%) samples were from female pa- 41–50 9 (40.9) 13 (59.1) 22 (12.0) tients, and 68 (68.3%) samples were positive for aerobic bacterial growth but there was no significant difference in 51–60 15 (68.2) 7 (31.8) 22 (12.0) between aerobic bacterial growth and gender of patients 61–70 8 (66.7) 4 (33.3) 12 (6.6) (p > 0.05) (Table 1). Highest rate of wound infection was 71–80 7 (77.8) 2 (22.2) 9 (5.0) observed among patients of age group ≤10 years (82.1%), Total 113 (62.00) 69 (38.00) 182 (100) followed by patients of age group 71–80 years (77.8%). Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 5 of 10 wards, orthopedic ward, ENT (eye-nose-throat), gentamycin and amikacin. A total of 50% of the K. pneu- gynecology wards) and from outpatient department. moniae isolates were sensitive to cotrimoxazole and ceftri- Eighty nine (48.9%) specimens were from traumatic cases, axone. All the isolates (100%) of both Proteus vulgaris and followed by 57 (31.3%) specimens which were from postop- P. mirabilis were susceptible to cefotaxime and amikacin. erative cases. The most common bacterial isolate was S. There was 100% resistant of P. mirabilis to cotrimoxazole aureus followed by E. coli. Out of 116 microbial isolates, 83 and cefazolin while 50% and 100% of P. vulgaris isolates (71.6%) were Gram-positive and among them, S. aureus 66 were resistant to cotrimoxazole and cefazolin respectively. (79.6%) was the most common isolate followed by CoNS 9 All isolates (100%) of C. freundii were resistant to ampicil- (10.8%), Enterococcus spp. 5 (6%) and Candida spp. 3 lin and cefazolin while 33.3% (1/3) were sensitive to cipro- (3.6%). On the other hand, 33 (28.4%) were Gram-negative floxacin, cotrimoxazole, cefotaxime, gentamycin and of which E. coli 10 (30.3%) was predominant isolate ceftriaxone (Table 3). followed by K. pneumoniae 6 (18.2%), Acinetobacter spp. 6 (18.2%), P. aeruginosa 5 (15.1%), C. freundii 3(9.1%), P. Antibiogram result of gram positive S. aureus, CoNS, and vulgaris 2 (6.1%) and P. mirabilis 1(3%). Inpusswab, S. Enterococcus species aureus (58%) was the predominant isolate followed by E. Among total isolated S. aureus,77.3% of S. aureus were coli (10%) and CoNS (9%). Similarly, in case of aspirates susceptible to gentamycin, where 75.8% of the isolates pus samples, S. aureus (50%) was the highest followed by K. were susceptible to cefotaxime. Similarly, 45.5% of S. aur- pneumoniae (18.7%) (Table 2 and Additional file 1). eus were susceptible to ciprofloxacin while 39.4% of S. aureus isolates were susceptible to cefoxitin. Eighty per- Antibiogram result of gram negative bacteria isolated from cent of Enterococcus spp. were sensitive to tetracycline. patients at KIST Hospital, November 2014 to august 2015 (Table 4). Among 66 S. aureus isolated from pus swab and A total of 10 E. coli were isolated from wound specimens aspirated pus, 40 (60.6%) isolates of S. aureus were MRSA. and 80% (8/10) of isolates were sensitive to gentamicin, 60% were sensitive to ciprofloxacin, 50% were sensitive to ESBL producers among Enterobacteriaceae isolates cefotaxime and 40% were sensitive to cotrimoxazole. All Among 10 isolates of E. coli, 2 (25%) were positive for isolates of E. coli (100%) were resistant to ampicillin ESBL and among 6 isolates of K. pneumoniae, 2 (40%) followed by cefazolin (80%) and ceftriaxone (70%). All the were positive for ESBL. Additionally, among 3 isolates of isolates of P. aeruginosa (100%) were susceptible to amika- C. freundii, 1 (33.3%) was ESBL positive whereas Proteus cin, tobramycin and imipenem while 80% of the P. aerugi- spp. were negative for ESBL (Table 5). nosa isolates were sensitive to ciprofloxacin. In contrast, 40% and 60% of P. aeruginosa isolates were resistant to Antibiogram result of isolates ceftazidime and piperacillin respectively. Similarly, 83.3% Eighty percent (80%) of E. coli and 68.2% of S. aureus (6/5) of K. pneumoniae were sensitive to meropenem were MDR (resistant to two or more than two anti- while 66.7% of isolates were susceptible to ciprofloxacin, microbial classes) strains. Similarly, 80% of P. aeruginosa and 77.7% of CoNS were MDR strains. Additionally, 83.3% of K. pneumoniae isolates were resistant to at least Table 2 Pattern of microbial isolates in wound samples two different classes of used antibiotics. In this study, Type of organism Type of Specimens Total 50% of Proteus spp. isolates were MDR (Table 6). Pus swab Aspirated pus No. % No. % No. % Discussion S. aureus 58 58 8 50 66 56.9 Aerobic bacteria causing wound infections were isolated E. coli 10 10 –– 10 8.6 and identified from pus specimens by series of biochem- ical tests and their antimicrobial susceptibility patterns to P. aeruginosa 55 –– 5 4.3 commonly used antibiotics in study area were examined. CoNS 9 9 –– 9 7.8 Enterobacteriaceae isolates were further processed for Acinetobacter spp. 6 6 –– 6 5.2 confirmation of ESBL producer. In this study, 60.4% of Enterococcus spp. 3 3 2 12.5 5 4.3 culture positive specimens showed monomicrobial C. freundii 1 1 2 12.5 3 2.6 growth, 1.7% showed polymicrobial and 37.9% were nega- K. pneumoniae 3 3 3 18.7 6 5.2 tive for aerobic bacterial growth. This finding is consistent with previous studies conducted by Egbe et al. and Kumari P. vulgaris 22 –– 2 1.6 et al. [19, 20]. Bhatta et al., [21]havereported 60%of bac- P. mirabilis 11 –– 1 0.9 terial wound infection from Nepal in 2008. Out of 182 Candida spp. 2 2 1 6.3 3 2.6 non-repeated samples analyzed, 143 (78.6%) samples were Total 100 100 16 100 116 100 from inpatients, where 98 (68%) were positive for aerobic Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 6 of 10 Table 3 Antibiotic susceptibility test result of Gram negative bacteria isolated from pus specimens Isolates Antimicrobial agents RXN AMP AK CIP COT GEN CTX CTR CZ MRP E.. coli (10) S 0 Nt 6 (60) 4 (40) 8 (80) 5 (50) 3 (30) 2 (20) Nt R 10 (100) Nt 4 (40) 6 (60) 2 (20) 5 (50) 7 (70) 8 (80) Nt P. aeruginosa (5) S Nt 5 (100) 4 (80) Nt Nt Nt Nt Nt Nt R Nt 0 1 (20) Nt Nt Nt Nt Nt Nt K. pneumoniae (6) S Nt 4 (66.7) 4 (66.7) 3 (50) 4 (66.7) Nt 3 (50) Nt 5 (83.3) R Nt 2 (33.3) 2 (33.3) 3 (50) 2 (33.3) Nt 3 (50) Nt 1 (16.7) P. vulgaris (n = 2) S 0 2 (100) 1 (50) 1 (50) Nt 2 (100) Nt 0 Nt R 2 (100) 0 1 (50) 1 (50) Nt 0 Nt 2 (100) Nt P. mirabilis (n = 1) S 1 (100) 1 (100) 1 (100) 0 Nt 1 (100) Nt 0 Nt R 0 0 0 1 (100) Nt 0 Nt 1 (100) Nt C. freundii (3) S 0 Nt 1 (33.3) 1 (33.3) 1 (33.3) 1 (33.3) 1 (33.3) 0 Nt R 3 (100) Nt 2 (66.7) 2 (66.7) 2 (66.7) 2 (66.7) 2 (66.7) 3 (100) Nt Acinetobacter spp. (n = 6) S 2 (33.3) 4 (66.7) 4 (66.7) 3 (50) 4 (66.7) 3 (50) Nt 3 (50) Nt R 4 (66.7) 2 (33.3) 2 (33.3) 3 (50) 2 (33.3) 3 (50) Nt 3 (50) Nt Antimicrobial agents RXN AMP AK CIP CAZ TOB IMP PI CZ MRP P. aeruginosa (5) S Nt 5 (100) 4 (80) 2 (40) 5 (100) 5 (100) 3 (60) Nt Nt R Nt 0 1 (20) 3 (60) 0 0 2 (40) Nt Nt Total (n = 38) S 3 (13.6) 21 (84) 25 (65.7) 14 (42.4) 22 (73.3) 17 (63) 10 (41.7) 5 (22.7) 5 (83.3) R 19 (86.4) 4 (16) 13 (34.3) 19 (57.6) 8 (26.7) 10 (37) 14 (58.3) 17 (77.3) 1 (16.7) Nt not tested, S Sensitive, R Resistant, RXN Reaction, AMP Ampicillin, AK Amikacin, CIP Ciprofloxacin, COT trimethoprim + sulfamethoxazole (cotrimoxazole), GEN Gentamicin, CTX Cefotaxime, Caz Ceftazidime, TOB Tobramycin, IMP Imipenem, PI Piperacillin, CTR Ceftriaxone, CZ Cefazolin, MRP Meropenem bacterial growth. Our finding shows higher rate of wound found the similar prevalence rate in Nepal before. Pus as- infection in inpatients (68%) as compare to outpatients piration is generally taken as sample of choice from deep (39%) and the result was statistically significant (p <0.05). seated and closed wound infections [22, 23]. Similar finding was reported by Stephen et al. [19]. Eighty one (44.5%) pus specimens were collected from Among 182 specimens collected, 156 (85.7%) were pus male patients, while 101 (55.5%) specimens were from fe- swabs with 64% (100/156) aerobic bacterial growth and 26 male patients and the result was statistically insignificant (14.3%) were aspirated pus where 13 (50%) were positive (p > 0.05). In this study, female patients outnumbered the for aerobic bacterial growth. Shrestha et al., [21]have male patients [24] but other studies showed wound Table 4 Antibiotic susceptibility test result of Gram positive bacteria isolated from pus specimens Isolates Antimicrobial agents RXN AMP AK CIP COT GEN CTX CX TE S. aureus (n = 66) S 5 (7.6) Nt 37 (56.1) 26 (39.4) 54 (81.8) 53 (80.3) 26 (39.4) 29 (43.9) R 61 (92.4) Nt 29 (43.9) 40 (60.6) 12 (18.2) 13 (19.7) 40 (60.6) 37 (56.1) CoNS (n = 9) S 1 (11.1) Nt 3 (33.3) 4 (44.4) 6 (66.7) 2 (22.2) 4 (44.4) 5 (55.6) R 8 (88.9) Nt 6 (66.7) 5 (55.6) 3 (33.3) 7 (77.8) 5 (55.6) 4 (44.4) Enterococcus spp. (n = 5) S 3 (60) 2 (40) 3 (60) 3 (60) 3 (60) 3 (60) Nt 4 (80) R 22 (40) 3 (60) 2 (40) 2 (40) 2 (40) 2 (40) Nt 1 (20) Total (n = 80) S 9 (11.25) 2 (40) 43 (53.75) 33 (41.25) 63 (78.75) 58 (72.5) 30 (40) 38 (47.5) R 71 (88.75) 3 (60) 37 (46.25) 47 (58.75) 17 (21.25) 22 (27.5) 45 (60) 42 (52.5) Nt not tested, S Sensitive, R Resistant, RXN Reaction, AMP Ampicillin, AK Amikacin, CIP Ciprofloxacin, COT trimethoprim + sulfamethoxazole (cotrimoxazole), GEN Gentamicin, CTX Cefotaxime, CX Cefoxitin, TE Tetracycline Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 7 of 10 Table 5 ESBL producers among Enterobacteriaceae that might be the reason for them being more prone to wound infections. Ranjan et al. have reported more patho- Bacterial Total ESBL producer isolates genic strains from patients of age group 21–40 years in No. % post-operative wound infections in India [30]. E. coli 10 2 25.0 Among 116 bacterial isolates, 11 different species were K. pneumoniae 6 2 40.0 identified. S. aureus (56.9%) was the most common iso- P. vulgaris 20 0 late followed by E. coli (8.6%) and CoNS (7.8%). Other P. mirabilis 10 0 identified bacteria from pus specimens included P. aeru- C. freundii 3 1 33.3 ginosa (4.3%), Acinetobacter spp. (5.2%), Enterococcus spp. (4.3%), C. freundii (2.6%), K. pneumoniae (5.2%), P. vulgaris (1.6%), and P. mirabilis (0.9%). The predomin- infection was higher in male as compared to female [25, ance of S. aureus in wound infection is supported by dif- 26]. In our study, lower number of male patients ferent studies [21, 30]. As being a normal flora of (44.5%) might be due to small sample size as compared human skin, it can get access into the wound easily. to other studies. In this study, monomicrobial growth Kansakar et al., [32] have reported that 82.5% of bacter- (97.3%) was higher than polymicrobial growth (2.7%) ial growth in pus samples and 13 different bacterial spe- both in pus swab and aspirated pus. Multiple studies cies were isolated where S. aureus was predominant carried out in wound infections have shown higher rate (57.7%) species followed by E. coli (11%) and CoNS (3%). of monomicrobial infection than polymicrobial infec- According to Mumtaz et al., [33] S. aureus was the most tion [27]. Similarlyahighrate(86–100%) of monomi- common bacteria (49%) found in wound infections crobial wound infection was reported from different followed by E. coli (25.9%), Klebsiella spp. (9.5%), P. aer- states of India [28, 29]. uginosa (8.6%), Proteus spp. (4%) and Acinetobacter Among different age groups, the prevalence of wound (2.7%) spp. S. aureus is the most common strain (25%) infections was highest among age group ≤10 years as a commensal organism of human skin and nasal pas- (82.1%) followed by age group 70–80 years (77.8%). This sage. Hence, most frequent isolation of S. aureus from is in agreement with study carried by Lakhey et al. where pus specimens might also be due to contamination of higher prevalence of wound infection was reported among collected specimens with skin normal flora [31]. Contri- patients of age group 60–80 years [20]. Similarly, in a study bution of multidrug resistant Acinetobacter spp. to noso- done by Mohammedaman et al., [5] in South Ethiopia, comial infections has increased over the past decade, 87.5% wound infection was in patients with age ≥ 60 years. and many outbreaks involving this bacterium have been Since old individuals and children have weak immunity, reported worldwide [32]. Table 6 Antibiogram result of isolates Isolated organisms Antibiogram Total MDR [N(%)] No. (%) of resistance R2 R3 R4 R5 Gram positive S. aureus (n = 66) 20 (30.3) 18 (27.3) 3 (4.5) 4 (6.1) 45 (68.2) CoNS (n = 9) 4 (44.4) 1 (11.1) 2 (22.2) 0 7 (77.7) Enterococcus spp. (n = 5) 3 (60) 0 1 (20) 0 4 (80) Total (n = 80) 27 (33.75) 19 (23.75) 6 (7.5) 4 (5) 56 (70) Gram negative E. coli (n = 10) 6 (60) 1 (10) 0 1 (10) 8 (80) P. aeruginosa (n = 5) 2 (40) 1 (20) 1 (20) 0 4 (80) Acinetobacter spp. (n = 6) 2 (33.3) 1 (16.7) 1 (16.7) 0 4 (66.7) C. freundii (n = 3) 2 (66.7) 0 0 0 2 (66.7) K. pneumoniae (n = 6) 2 (33.3) 1 (16.7) 0 2 (33.3) 5 (83.3) P. vulgaris (n = 2) 1 (50) 0 0 0 1 (50) P. mirabilis (n = 1) 1 (50) 0 0 0 1 (50) Total (n = 33) 10 (30.3) 3 (9.1) 2 (6.1) 2 (6.1) 17 (51.5) R2-R5 number of antibiotics class where an isolate was resistant Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 8 of 10 Shrestha et al., [21] have found that 85% of S. aureus iso- respectively. The prevalence rate may vary based on lates were sensitive to ciprofloxacin, 83% and 82% were sample collection method, site of sample collection, mi- sensitive to cephalexin and cotrimoxazole respectively. In crobial detection technique, antimicrobial agents used, this study, 60.6% of Staphylococci isolates were resistant to and geographical location. In this study, 68.2% of S. aur- cefoxitin. S. aureus which was resistant to cefoxitin anti- eus and 80% of E. coli isolates were MDR strains. The biotic was reported as MRSA species. Rajbhandari et al., highest rate (83.3%) of MDR was observed in K. pneu- [36] have also reported 61.6% of MRSA prevalence in moniae. This finding is in agreement with the study con- wound infection. The second common isolate of this study ducted in South-West Ethiopia by Mohammedaman et was E. coli where 80%, 60%, 50% and 40% of the isolates al. [5]. Most of the Gram negative isolates were resistant were susceptible to gentamycin, ciprofloxacin, cefotaxime to ampicillin (86.4%) and cefazolin (77.3%) while 88.6% and cotrimoxazole respectively. All the isolates of E. coli and 60% of Gram positive bacteria were resistant to (100%) were resistant to ampicillin where 30% and 20% ampicillin and amikacin respectively. In Nepal, oral ad- were resistant to ceftriaxone and cefazolin respectively. ministration of antibiotics is common practice which Similarly, 60% and 40% of E. coli isolates were susceptible may reduce absorption of antibiotics by blood stream. to ciprofloxacin and cotrimoxazole respectively. This study Long term use of antibiotics via oral route could con- showed low sensitivity rate as compared to other studies tribute to bacteria developing resistance. [33]. Hence, increased antimicrobial resistant rate of E. coli Wound infection is a burning public health issue espe- depicts its important role in nosocomial infections. cially in developing countries. Severe wound infection can All the isolates of P. aeruginosa (100%) were sensitive to cause great loss including higher rate of morbidity and amikacin, tobramycin and imipenem while 80% and 60% mortality; longer hospital stays, delay in wound healing, were sensitive to ciprofloxacin and piperacillin respect- increase economic burden and increase discomfort which ively. Only 40% of the P. aeruginosa were susceptible to in turn increases disease burden significantly. Wound in- the antibiotic ceftazidime. In a study conducted by fection is being a common nosocomial infections which Shrestha et al., [21] 93% of isolates were sensitive to ami- accounts for 0–80% of patient’s mortality [35, 36]. kacin and 66.7% of isolates were sensitive to ciprofloxacin. Modernization in control and prevention of infections Our finding in this context is similar with other results has not completely controlled wound infection due to in- where P. aeruginosa isolated from pus samples has shown creasing problem of antimicrobial resistance [37]. As com- least resistance to ciprofloxacin (6.2–24%) [34]. More pared to previous studies, antimicrobial resistance pattern prevalence of antimicrobial resistant P. aeruginosa in is increasing at high rate. Multiple factors may contribute wound infection is being a challenging issue especially in to rapid development of antimicrobial resistance by patho- resource limited countries [26]. gens including misuse, overuse, and underuse of antimi- K. pneumoniae was most sensitive to meropenem crobials by both clinicians and patients. In Nepal, people (83.3%) and 66.7% of K. pneumoniae isolates were equally purchase antimicrobials without physician’sprescription, resistant to gentamycin, ciprofloxacin, and amikacin which is a common practice. This leads to misuse of anti- where 50% of isolated K. pneumoniae were resistant to microbials that contributes to the emergence and spread cotrimoxazole and ceftriaxone. In a study reported by of antimicrobial resistant strain. MRSA and ESBL produ- Mohammedaman et al., [5]35.7% of K. pneumoniae were cing bacteria are creating a serious problem in wound resistant to ciprofloxacin and doxycycline. Furthermore, treatment in different parts of the country. Rajput et al., [24] had reported that 45.5% and 80% of K. pneumoniae strains were resistant to ciprofloxacin and cotrimoxazole respectively. All isolates (100%) of P. vul- Conclusion garis were susceptible to amikacin, and cefotaxime but In this study, the most common isolate was S. aureus in 100% of P. vulgaris isolates were resistant to ampicillin pus specimens. Among S. aureus isolates, 60.6% were and cefazolin while 50% of isolated P. vulgaris were resist- MRSA strains, whereas 40% of K. pneumoniae and ant to ciprofloxacin and cotrimoxazole. All isolates (100%) 33.3% C. freundii were ESBL producer followed by E. of P. mirabilis were sensitive to ciprofloxacin, amikacin coli (25%). Eighty percent (80%) of E. coli, P. aeruginosa, and cefotaxime whereas 100% were resistant to ampicillin, and 68.2% of S. aureus were MDR strains. This study cotrimoxazole and cefazolin. This result is comparable emphasizes the importance of strict nosocomial infec- with study carried by Bhatta et al. [20]. tion control strategies and careful prescription of antimi- Among Enterobacteriaceae isolates, 25% of E. coli, 40% crobials should be implemented by the health care of K. pneumoniae and 33.3% of C. freundii were ESBL centres. It should be mandatory to screen out ESBL, producer. But none of the Proteus species were ESBL MRSA, and MDR pathogens and regular monitoring of producer. Chander et al., [35] have reported 13.51% and their antimicrobial susceptibility pattern for prevention 16.55% of E. coli and K. pneumoniae as ESBL producer and control of wound infections. Early reporting of drug Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 9 of 10 resistant pathogens and evidence-based treatment algo- Received: 31 July 2018 Accepted: 17 September 2018 rithm can control the wound infections. Research on AMR is in its infancy stage in Nepal, but it is paramount to establish surveillance programs to reduce burden of References 1. 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J Microbiol Antimicrob. 2011;3(9):68–75. 29. Lakshmidevi N. Surgical site infections: assessing risk factors, outcomes and antimicrobial sensitivity patterns. Afr J Microbiol Res. 2009;3(4):175–9. 30. Mulu W, Kibru G, Beyene G, Damtie M. Postoperative nosocomial infections and antimicrobial resistance pattern of bacteria isolates among patients admitted at Felege Hiwot referral hospital, Bahirdar, Ethiopia. Ethiop J Health Sci. 2012;22(1):7–18. 31. Adegoke AA, Komolafe AO. Nasal colonization of school children in Ile-Ife by multiple antibiotic resistant Staphylococcus aureus. Int J Biotechnol Allied Sci. 2008;3(1):317–22. 32. Forster, D.H. and Daschner, F.D., 1998. Acinetobacter species as nosocomial pathogens. 33. Biadglegne F, Abera B, Alem A, Anagaw B. Bacterial isolates from wound infection and their antimicrobial susceptibility pattern in Felege Hiwot referral Hospital North West Ethiopia. Ethiop J Health Sci. 2009;19(3):173–177. 34. Manyahi J. Bacteriological spectrum of post operative wound infections and their antibiogram in a Tertiary Hospital, Dar Es Salaam, Tanzania (Doctoral dissertation, Muhimbili University of Health and Allied Sciences). 35. Gottrup F, Melling A, Hollander DA. An overview of surgical site infections: aetiology, incidence and risk factors. EWMA J. 2005;5(2):11–5. 36. Howell-Jones RS, Wilson MJ, Hill KE, Howard AJ, Price PE, Thomas DW. A review of the microbiology, antibiotic usage and resistance in chronic skin wounds. J Antimicrob Chemother. 2005;55(2):143–9. 37. Heinzelmann M, Scott M, Lam T. Factors predisposing to bacterial invasion and infection. Am J Surg. 2002;183(2):179–90. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Antimicrobial Resistance and Infection Control Springer Journals

Prevalence of methicillin resistant Staphylococcus aureus, multidrug resistant and extended spectrum β-lactamase producing gram negative bacilli causing wound infections at a tertiary care hospital of Nepal

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Springer Journals
Copyright
Copyright © The Author(s). 2018
Subject
Biomedicine; Medical Microbiology; Drug Resistance; Infectious Diseases
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2047-2994
DOI
10.1186/s13756-018-0408-z
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Abstract

Background: Treatment and prevention of wound infection continues to be a challenging issue in clinical settings of Nepal especially in the context of globally growing problem of antimicrobial resistance. Study on opportunistic pathogens and sensitivity to commonly prescribed local antimicrobial agents are cardinal to reduce the disease burden of wound infections. The aim of this study was to determine the prevalence and antimicrobial susceptibility pattern of methicillin resistant Staphylococcus aureus (MRSA) and extended spectrum β-lactamase (ESBL) producing bacteria from wound infections of patients at a tertiary care hospital in Nepal. Methods: Pus specimens were processed using standard microbiological procedures. Antimicrobial susceptibility test was performed following the modified Kirby Bauer disc diffusion technique. Clinical information of patients was obtained from preformed questionnaire and hospital record. Results: One hundred eighty two pus specimens from wounds of different body parts: leg, hand, backside, abdominal part, foot, breast and chest, head and neck region were collected and analyzed; 113 bacterial isolates were isolated showing the overall bacterial growth rate of 62%, where the highest rate was among patients of ≤10 years age group (82.1%). A higher rate (68.5%) of bacterial isolates were from inpatients (p < 0.05). Among 116 bacterial isolates, Staphylococcus aureus was the most predominant bacteria (56.9%) followed by Escherichia coli (8.6%), coagulase negative staphylococci (7.8%), Acinetobacter spp. (5.2%), Klebsiella pneumoniae (5.2%), Pseudomonas aeruginosa (4.3%), Enterococcus spp. (4.3%), Citrobacter freundii (2.6%), Proteus vulgaris (1.6%) and P. mirabilis (0.9%). Both Gram positive (73.3%) and negative (78.8%) isolates showed high frequency of sensitive to gentamycin. Conclusion: Among S. aureus isolates, 60.6% were MRSA strains, whereas 40% of K. pneumoniae and 33.3% of C. freundii were ESBL producing bacteria followed by E. coli (25%). It is thus paramount to address the burden of silently and speedily increasing infections caused by drug resistant strains of MRSA and ESBL in Nepal. Keywords: Wound infection, Methicillin resistant Staphylococcus aureus, ESBL, Multidrug resistant, Nepal * Correspondence: upreti.naru@gmail.com; rayamajheebinod@gmail.com Central Department of Microbiology, Tribhuvan University, Kirtipur, Nepal National College (Tribhuvan University), Khusibu, Kathmandu, Nepal Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 2 of 10 Background evidence-based treatment algorithm can control the Wound infections result after the active interactions that wound infections. takes place between a host, a potential pathogen and the surrounding extrinsic factors. The intensity of wound in- Methods fections may range from a simple self-healing to a severe Study site and population and life threatening [1]. Tissue invasion by bacterial path- A descriptive cross-sectional study was designed and ogens is determined by the location of wound [2]. The carried out to determine the bacteriological profile of common bacterial pathogens isolated from wound wound infections. MRSA, MDR and ESBL producing infections are Staphylococcus aureus, S. epidermidis, S. bacteria were identified from the pus samples of patients pyogenes, coagulase negative staphylococci (CoNS), Acine- with wound infection visiting KIST Medical College and tobacter spp., Pseudomonas spp., Escherichia coli, Klebsi- Teaching Hospital, Kathmandu, Nepal from November ella spp., Proteus spp., Enterobacter spp., Citrobacter spp., 2014 to August 2015. A total of 182 pus and Fine Needle and anaerobes such as Clostridium spp. and Peptostrepto- Aspirate specimens were collected from patients with coccus spp. [3, 4]. Acquisition of drug resistance by these clinical features of wound infection like patients with pathogenic strains has posed serious challenges for the pain, complaints of regular discharge, foul smelling and remedy and management of wound infections around the red swelling. During the study, patients of all age groups world [5]. Wound infections can be monomicrobial or and both genders from out-patients (39/182) and polymicrobial [6]. The presence of bacterial pathogens in in-patients (143/182) were included. Patients who were wound infections is not uncommon but all wounds do not admitted in the hospital for more than 3 days and/or in support the same range and number of species [7]. prior antibiotic treatment and anaerobic wound infec- Hospital-acquired wound infections are the leading cause tions were excluded from this study. of morbidity hence, proper management of wound infec- tion in clinical settings is paramount [8]. The treatment of Sampling procedure wound infections is being more challenging due to methi- Pus specimens were collected from elective surgery cillin resistant S. aureus (MRSA), involvement of polymi- wounds of hospital wards [surgical, post- operative, crobial flora and fungi [9]. In addition, antimicrobial trauma, orthopedic, ENT (eye-nose-throat), gynecology resistance (AMR) is creating a serious problem in all clin- wards], open and dressed wounds. Sterile cotton swabs ical settings and AMR has become the biggest public and fine needle syringes (FNS) were used to collect pus health threat globally [10]. samples from open wounds then each sample was la- MRSA, a leading strain of wound infections, involves beled properly with date/time of sample collection, col- significant areas of skin or deeper soft tissues like ab- lection method and the patient’s details. Swabs from scesses, cellulitis, burns or infected deep ulcers [11]. open wounds were aseptically collected after cleaned off Extended spectrum β- lactamase (ESBL) producing En- while pus from dressed wounds were collected after re- terobacteriaceae are also in frontline of wound infections. moving the dressing items. The information of each pa- In ESBL, positive strains plasmid mediated AmpC en- tient was recorded such as site of infection, signs and zymes, and carbapenem hydrolyzing β- lactamase (carba- symptoms, other underlying diseases, and prior antibi- penemases) conferred resistance to the newer β- lactam otics administration. Before collecting the sample, the antimicrobials [12]. ESBL have been reported most fre- area was rinsed with sterile normal saline and then a quently in Escherichia coli and Klebsiella spp. including sterile cotton swab was gently rolled over the surface of other bacterial species such as Salmonella enterica, P. aer- the wound. The swab with pus was kept in a sterile test uginosa,and Serratia marcescens [13]. This surge in anti- tube with cap where details was labeled properly. For microbial resistance further delays wound healing and the the collection of pus sample from deep wounds, FNS infection becomes more worst which increases hospital was used. Specimens were collected from wounds of dif- stay, prolongs trauma care, and high medical costs [14]. ferent body parts: leg, hand, back part of body, abdom- On the other hand, most of the clinical laboratories in inal part, foot region, breast and chest part, head and underdeveloped countries are not equipped with testing neck region. Amies transport medium was used to trans- facilities to detect ESBL producing bacteria. In Nepal, port the collected specimens. For Fine Needle Aspiration there is scanty data on the prevalence of ESBL-producing Cytology (FNAC), the syringe was properly capped, la- bacteria causing wound infections. The goal of this beled and dispatched to the laboratory immediately. study was to determine the prevalence of MRSA, multi- drug resistant and ESBL producing Gram negative ba- Processing of samples cilli from wound infections of patients visiting KIST Macroscopic examination of samples Medical College and Teaching Hospital, Lalitpur, Among 182 pus specimens collected, 56 (30.8%) were Nepal. Early reporting of drug resistant pathogens and from the leg region, 43 (23.6%) from hand, 15 (8.2%) Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 3 of 10 from back part of body, 14 (7.8%) from abdominal part, (5 μg), cefazolin (30 μg), ceftriaxone (30 μg), cefotaxime 15 (8.2%) from foot region, 6 (3.3%) from breast and chest (30 μg), amikacin (30 μg), piperacillin (100 μg), tobra- part, and 33 (18.1%) were from head and neck region mycin (10 μg), imipenem (10 μg), and meropenem wounds. All the specimens were visually examined for (10 μg). After 24 h of incubation period at 37 C, the zone consistency, color, turbidity, presence or absence of blood of inhibition (ZOI) was measured then the results were depending upon the type and site of wound. Additionally, analyzed according to the guidelines issued by the Clinical pus swabs were observed whether they were labeled cor- Laboratory Standard Institute (CLSI - M100-S25, 2015) rectly or not. [16]. Isolates resistant to two or more antimicrobial classes were reported as multi drug resistant (MDR) strains. Anti- Microscopic examination of samples microbials and their doses were selected based on pre- After transportation of specimens to the laboratory, Gram scription frequency by physician and availability in the staining of each specimens was performed [15]. study setting. Minimum inhibitory and bactericidal con- centration (MIC and MBC) of used antimicrobials were Culture of specimens and identification of isolated bacteria not determined due to unavailability of all antimicrobials Pus specimens were inoculated into Chocolate agar, Blood powder at the time of study period. agar, MacConkey agar, Nutrient agar and Potato Dextrose agar plates as per the clinical laboratory guidelines [16]. Screening and confirmation for ESBL producers The preliminary identification of the isolated bacteria was Enterobacteriaceae isolates were screened for possible done based on colony form, size, shape, pigmentation, ESBL producing bacteria using antibiotic discs of cefo- margin, and elevation. The isolated organisms were identi- taxime (30 μg), ceftazidime (30 μg), ceftriaxone (30 μg) fied by performing different biochemical tests and Gram and aztreonam (30 μg) [17]. According to the guidelines, staining then antimicrobial susceptibility tests were per- bacterial isolates showing ceftazidime < 22 mm, and cef- formed. In case of no growth after 24 h of incubation fur- otaxime < 27 mm are the possible ESBL producer. The ther incubation was done up to 48 h at 37 C. After proper suspected ESBL producer strains were subjected to incubation period, the culture plates were examined for double disc synergy test (DDST) for the confirmation of microbial growth. In every case, each plate was carefully ESBL producing Enterobacteriaceae [18]. observed. Then, biochemical tests were performed in ster- ile media for the identification of bacterial isolates. Identi- Statistical analysis fication of Staphylococci spp. was done by Gram staining, All data were examined using iBM SPSS version 21.0. catalase test, slide coagulase and tube coagulase test. Simi- Frequencies were calculated for categorical variables. larly, Gram negative strains were identified based on result Chi-square test was calculated to analyze significant dif- of different biochemical tests; Oxidase, Catalase, Methyl ference at 95% of confidence level, p value of < 0.05 was Red (MR), Voges Proskauer (VP), Citrate utilization, Urea considered significant, unless otherwise noted. Hydrolysis, Triple Sugar Iron agar (TSI), Sulfide Motility and Indole test. Colony morphology and microscopic ob- Quality control servation were taken in account for identification of All prepared biochemical and streaking media were Candida spp. checked for their sterility. Strains of E. coli ATCC 25922 and S. aureus ATCC 25923 were used as reference strains Examination of antimicrobial susceptibility pattern of for quality control of AST and biochemical tests. The isolated organism same strain of E. coli was also considered as a negative Antimicrobial susceptibility pattern was performed for control during the screening and phenotypic confirmation isolated and identified bacteria from pus samples follow- (DDST) tests of ESBL producing Gram-negative bacilli. ing the modified Kirby Bauer disc diffusion technique. A dilution of the identified organism was prepared compar- Results ing with the standard 0.5 McFarland turbidity which was Bacterial growth used to swab over the Mueller Hinton agar (MHA) A total of 182 samples were collected and examined medium for the antimicrobial susceptibility test (AST). from hospital patients with clinical features of wound in- Discs of antibiotic used for Gram positive bacteria were fection, 113 (62%) specimens were positive for aerobic ampicillin (10 μg), cefotaxime (30 μg), gentamycin (10 μg), bacterial growth. Out of 116 bacterial isolates obtained ciprofloxacin (5 μg), trimethoprim + sulfamethoxazole from 113 positive samples, 83 (71.6%) bacterial isolates (25 μg), cefoxitin (30 μg), amikacin (30 μg) and tetracyc- were Gram positive and 33 (28.4%) isolates were Gram line (30 μg) whereas antibiotics used for Gram negative negative. Among processed specimens, 64% (100/156) of organisms were ampicillin (10 μg), trimethoprim + sulfa- pus swabs and 50% (13/26) of aspirated pus specimens methoxazole (25 μg), gentamycin (10 μg), ciprofloxacin have shown aerobic bacterial growth (Fig. 1). Out of 113 Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 4 of 10 Fig. 1 Percentage of bacterial growth in pus swab and aspirated pus swab specimens positive for aerobic bacterial culture, polymi- Growth pattern in outpatient and inpatient departments crobial growth was observed in 3 (2.7%) specimens One hundred forty three samples were from inpatient de- where combinations of S. aureus - Acinetobacter spp., partment (from different wards) and 39 samples were S. aureus - Citrobacter freundii and Enterococcus spp. from outpatient department. Out of 143 samples from in- - Candida spp. were reported. High incidence of MRSA patient, 98 (68.5%) were positive and out of 39 samples 60.6% (40/66), MDR (80% of E. coli,68.2% of S. aureus, from outpatient, 15 (38.5%) were positive for bacterial 80% of P. aeruginosa, 77.7% of CoNS and 50% of Proteus growth. Type of patients based on department had a posi- spp.) and ESBL (25% of E. coli,40% of K. pneumoniae,and tive correlation with aerobic bacterial growth (p <0.05). 33.3% of C. freundii) producing isolates were reported in Pus specimens were collected from inpatient depart- this study. ments/wards (such as surgical wards, post- operative Sixty two (34.1%) specimens processed were collected from the leg, 36 (19.8%) from hand, 16 (8.8%) from back- Table 1 Socio-demographic features of the patients and ratio side, 15 (8.2%) from abdominal, 22 (12.1%) from foot, 13 of wound infection (7.1%) from breast and chest, 18 (9.9%) from head and Demographic Infected Not infected Total neck part. Majority of patients (86%) were presented with features [No. (%)] [No. (%)] [No. (%)] fever, lethargy and muscle pain at the time of sample col- Sex lection. None of the patients were reported with any Male 45 (55.6) 36 (44.4) 81 (44.5) underlying diseases. Patients who had other infections and Female 68 (67.3) 33 (32.7) 101 (55.5) antibiotic treatment were excluded from the study subject. Total 113 (62.1) 69 (37.9) 182 (100) Age in years Wound infection in relation with demographic characteristics ≤ 10 23 (82.1) 5 (17.9) 28 (15.4) of the patients 11–20 18 (60.0) 12 (40.0) 30 (16.5) Eighty one (44.5%) samples were from male patients and 21–30 12 (44.4) 15 (55.6) 27 (14.9) among them 45 (55.5%) samples showed aerobic bacterial 31–40 21 (65.6) 11 (34.4) 32 (17.6) growth, while 101 (55.5%) samples were from female pa- 41–50 9 (40.9) 13 (59.1) 22 (12.0) tients, and 68 (68.3%) samples were positive for aerobic bacterial growth but there was no significant difference in 51–60 15 (68.2) 7 (31.8) 22 (12.0) between aerobic bacterial growth and gender of patients 61–70 8 (66.7) 4 (33.3) 12 (6.6) (p > 0.05) (Table 1). Highest rate of wound infection was 71–80 7 (77.8) 2 (22.2) 9 (5.0) observed among patients of age group ≤10 years (82.1%), Total 113 (62.00) 69 (38.00) 182 (100) followed by patients of age group 71–80 years (77.8%). Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 5 of 10 wards, orthopedic ward, ENT (eye-nose-throat), gentamycin and amikacin. A total of 50% of the K. pneu- gynecology wards) and from outpatient department. moniae isolates were sensitive to cotrimoxazole and ceftri- Eighty nine (48.9%) specimens were from traumatic cases, axone. All the isolates (100%) of both Proteus vulgaris and followed by 57 (31.3%) specimens which were from postop- P. mirabilis were susceptible to cefotaxime and amikacin. erative cases. The most common bacterial isolate was S. There was 100% resistant of P. mirabilis to cotrimoxazole aureus followed by E. coli. Out of 116 microbial isolates, 83 and cefazolin while 50% and 100% of P. vulgaris isolates (71.6%) were Gram-positive and among them, S. aureus 66 were resistant to cotrimoxazole and cefazolin respectively. (79.6%) was the most common isolate followed by CoNS 9 All isolates (100%) of C. freundii were resistant to ampicil- (10.8%), Enterococcus spp. 5 (6%) and Candida spp. 3 lin and cefazolin while 33.3% (1/3) were sensitive to cipro- (3.6%). On the other hand, 33 (28.4%) were Gram-negative floxacin, cotrimoxazole, cefotaxime, gentamycin and of which E. coli 10 (30.3%) was predominant isolate ceftriaxone (Table 3). followed by K. pneumoniae 6 (18.2%), Acinetobacter spp. 6 (18.2%), P. aeruginosa 5 (15.1%), C. freundii 3(9.1%), P. Antibiogram result of gram positive S. aureus, CoNS, and vulgaris 2 (6.1%) and P. mirabilis 1(3%). Inpusswab, S. Enterococcus species aureus (58%) was the predominant isolate followed by E. Among total isolated S. aureus,77.3% of S. aureus were coli (10%) and CoNS (9%). Similarly, in case of aspirates susceptible to gentamycin, where 75.8% of the isolates pus samples, S. aureus (50%) was the highest followed by K. were susceptible to cefotaxime. Similarly, 45.5% of S. aur- pneumoniae (18.7%) (Table 2 and Additional file 1). eus were susceptible to ciprofloxacin while 39.4% of S. aureus isolates were susceptible to cefoxitin. Eighty per- Antibiogram result of gram negative bacteria isolated from cent of Enterococcus spp. were sensitive to tetracycline. patients at KIST Hospital, November 2014 to august 2015 (Table 4). Among 66 S. aureus isolated from pus swab and A total of 10 E. coli were isolated from wound specimens aspirated pus, 40 (60.6%) isolates of S. aureus were MRSA. and 80% (8/10) of isolates were sensitive to gentamicin, 60% were sensitive to ciprofloxacin, 50% were sensitive to ESBL producers among Enterobacteriaceae isolates cefotaxime and 40% were sensitive to cotrimoxazole. All Among 10 isolates of E. coli, 2 (25%) were positive for isolates of E. coli (100%) were resistant to ampicillin ESBL and among 6 isolates of K. pneumoniae, 2 (40%) followed by cefazolin (80%) and ceftriaxone (70%). All the were positive for ESBL. Additionally, among 3 isolates of isolates of P. aeruginosa (100%) were susceptible to amika- C. freundii, 1 (33.3%) was ESBL positive whereas Proteus cin, tobramycin and imipenem while 80% of the P. aerugi- spp. were negative for ESBL (Table 5). nosa isolates were sensitive to ciprofloxacin. In contrast, 40% and 60% of P. aeruginosa isolates were resistant to Antibiogram result of isolates ceftazidime and piperacillin respectively. Similarly, 83.3% Eighty percent (80%) of E. coli and 68.2% of S. aureus (6/5) of K. pneumoniae were sensitive to meropenem were MDR (resistant to two or more than two anti- while 66.7% of isolates were susceptible to ciprofloxacin, microbial classes) strains. Similarly, 80% of P. aeruginosa and 77.7% of CoNS were MDR strains. Additionally, 83.3% of K. pneumoniae isolates were resistant to at least Table 2 Pattern of microbial isolates in wound samples two different classes of used antibiotics. In this study, Type of organism Type of Specimens Total 50% of Proteus spp. isolates were MDR (Table 6). Pus swab Aspirated pus No. % No. % No. % Discussion S. aureus 58 58 8 50 66 56.9 Aerobic bacteria causing wound infections were isolated E. coli 10 10 –– 10 8.6 and identified from pus specimens by series of biochem- ical tests and their antimicrobial susceptibility patterns to P. aeruginosa 55 –– 5 4.3 commonly used antibiotics in study area were examined. CoNS 9 9 –– 9 7.8 Enterobacteriaceae isolates were further processed for Acinetobacter spp. 6 6 –– 6 5.2 confirmation of ESBL producer. In this study, 60.4% of Enterococcus spp. 3 3 2 12.5 5 4.3 culture positive specimens showed monomicrobial C. freundii 1 1 2 12.5 3 2.6 growth, 1.7% showed polymicrobial and 37.9% were nega- K. pneumoniae 3 3 3 18.7 6 5.2 tive for aerobic bacterial growth. This finding is consistent with previous studies conducted by Egbe et al. and Kumari P. vulgaris 22 –– 2 1.6 et al. [19, 20]. Bhatta et al., [21]havereported 60%of bac- P. mirabilis 11 –– 1 0.9 terial wound infection from Nepal in 2008. Out of 182 Candida spp. 2 2 1 6.3 3 2.6 non-repeated samples analyzed, 143 (78.6%) samples were Total 100 100 16 100 116 100 from inpatients, where 98 (68%) were positive for aerobic Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 6 of 10 Table 3 Antibiotic susceptibility test result of Gram negative bacteria isolated from pus specimens Isolates Antimicrobial agents RXN AMP AK CIP COT GEN CTX CTR CZ MRP E.. coli (10) S 0 Nt 6 (60) 4 (40) 8 (80) 5 (50) 3 (30) 2 (20) Nt R 10 (100) Nt 4 (40) 6 (60) 2 (20) 5 (50) 7 (70) 8 (80) Nt P. aeruginosa (5) S Nt 5 (100) 4 (80) Nt Nt Nt Nt Nt Nt R Nt 0 1 (20) Nt Nt Nt Nt Nt Nt K. pneumoniae (6) S Nt 4 (66.7) 4 (66.7) 3 (50) 4 (66.7) Nt 3 (50) Nt 5 (83.3) R Nt 2 (33.3) 2 (33.3) 3 (50) 2 (33.3) Nt 3 (50) Nt 1 (16.7) P. vulgaris (n = 2) S 0 2 (100) 1 (50) 1 (50) Nt 2 (100) Nt 0 Nt R 2 (100) 0 1 (50) 1 (50) Nt 0 Nt 2 (100) Nt P. mirabilis (n = 1) S 1 (100) 1 (100) 1 (100) 0 Nt 1 (100) Nt 0 Nt R 0 0 0 1 (100) Nt 0 Nt 1 (100) Nt C. freundii (3) S 0 Nt 1 (33.3) 1 (33.3) 1 (33.3) 1 (33.3) 1 (33.3) 0 Nt R 3 (100) Nt 2 (66.7) 2 (66.7) 2 (66.7) 2 (66.7) 2 (66.7) 3 (100) Nt Acinetobacter spp. (n = 6) S 2 (33.3) 4 (66.7) 4 (66.7) 3 (50) 4 (66.7) 3 (50) Nt 3 (50) Nt R 4 (66.7) 2 (33.3) 2 (33.3) 3 (50) 2 (33.3) 3 (50) Nt 3 (50) Nt Antimicrobial agents RXN AMP AK CIP CAZ TOB IMP PI CZ MRP P. aeruginosa (5) S Nt 5 (100) 4 (80) 2 (40) 5 (100) 5 (100) 3 (60) Nt Nt R Nt 0 1 (20) 3 (60) 0 0 2 (40) Nt Nt Total (n = 38) S 3 (13.6) 21 (84) 25 (65.7) 14 (42.4) 22 (73.3) 17 (63) 10 (41.7) 5 (22.7) 5 (83.3) R 19 (86.4) 4 (16) 13 (34.3) 19 (57.6) 8 (26.7) 10 (37) 14 (58.3) 17 (77.3) 1 (16.7) Nt not tested, S Sensitive, R Resistant, RXN Reaction, AMP Ampicillin, AK Amikacin, CIP Ciprofloxacin, COT trimethoprim + sulfamethoxazole (cotrimoxazole), GEN Gentamicin, CTX Cefotaxime, Caz Ceftazidime, TOB Tobramycin, IMP Imipenem, PI Piperacillin, CTR Ceftriaxone, CZ Cefazolin, MRP Meropenem bacterial growth. Our finding shows higher rate of wound found the similar prevalence rate in Nepal before. Pus as- infection in inpatients (68%) as compare to outpatients piration is generally taken as sample of choice from deep (39%) and the result was statistically significant (p <0.05). seated and closed wound infections [22, 23]. Similar finding was reported by Stephen et al. [19]. Eighty one (44.5%) pus specimens were collected from Among 182 specimens collected, 156 (85.7%) were pus male patients, while 101 (55.5%) specimens were from fe- swabs with 64% (100/156) aerobic bacterial growth and 26 male patients and the result was statistically insignificant (14.3%) were aspirated pus where 13 (50%) were positive (p > 0.05). In this study, female patients outnumbered the for aerobic bacterial growth. Shrestha et al., [21]have male patients [24] but other studies showed wound Table 4 Antibiotic susceptibility test result of Gram positive bacteria isolated from pus specimens Isolates Antimicrobial agents RXN AMP AK CIP COT GEN CTX CX TE S. aureus (n = 66) S 5 (7.6) Nt 37 (56.1) 26 (39.4) 54 (81.8) 53 (80.3) 26 (39.4) 29 (43.9) R 61 (92.4) Nt 29 (43.9) 40 (60.6) 12 (18.2) 13 (19.7) 40 (60.6) 37 (56.1) CoNS (n = 9) S 1 (11.1) Nt 3 (33.3) 4 (44.4) 6 (66.7) 2 (22.2) 4 (44.4) 5 (55.6) R 8 (88.9) Nt 6 (66.7) 5 (55.6) 3 (33.3) 7 (77.8) 5 (55.6) 4 (44.4) Enterococcus spp. (n = 5) S 3 (60) 2 (40) 3 (60) 3 (60) 3 (60) 3 (60) Nt 4 (80) R 22 (40) 3 (60) 2 (40) 2 (40) 2 (40) 2 (40) Nt 1 (20) Total (n = 80) S 9 (11.25) 2 (40) 43 (53.75) 33 (41.25) 63 (78.75) 58 (72.5) 30 (40) 38 (47.5) R 71 (88.75) 3 (60) 37 (46.25) 47 (58.75) 17 (21.25) 22 (27.5) 45 (60) 42 (52.5) Nt not tested, S Sensitive, R Resistant, RXN Reaction, AMP Ampicillin, AK Amikacin, CIP Ciprofloxacin, COT trimethoprim + sulfamethoxazole (cotrimoxazole), GEN Gentamicin, CTX Cefotaxime, CX Cefoxitin, TE Tetracycline Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 7 of 10 Table 5 ESBL producers among Enterobacteriaceae that might be the reason for them being more prone to wound infections. Ranjan et al. have reported more patho- Bacterial Total ESBL producer isolates genic strains from patients of age group 21–40 years in No. % post-operative wound infections in India [30]. E. coli 10 2 25.0 Among 116 bacterial isolates, 11 different species were K. pneumoniae 6 2 40.0 identified. S. aureus (56.9%) was the most common iso- P. vulgaris 20 0 late followed by E. coli (8.6%) and CoNS (7.8%). Other P. mirabilis 10 0 identified bacteria from pus specimens included P. aeru- C. freundii 3 1 33.3 ginosa (4.3%), Acinetobacter spp. (5.2%), Enterococcus spp. (4.3%), C. freundii (2.6%), K. pneumoniae (5.2%), P. vulgaris (1.6%), and P. mirabilis (0.9%). The predomin- infection was higher in male as compared to female [25, ance of S. aureus in wound infection is supported by dif- 26]. In our study, lower number of male patients ferent studies [21, 30]. As being a normal flora of (44.5%) might be due to small sample size as compared human skin, it can get access into the wound easily. to other studies. In this study, monomicrobial growth Kansakar et al., [32] have reported that 82.5% of bacter- (97.3%) was higher than polymicrobial growth (2.7%) ial growth in pus samples and 13 different bacterial spe- both in pus swab and aspirated pus. Multiple studies cies were isolated where S. aureus was predominant carried out in wound infections have shown higher rate (57.7%) species followed by E. coli (11%) and CoNS (3%). of monomicrobial infection than polymicrobial infec- According to Mumtaz et al., [33] S. aureus was the most tion [27]. Similarlyahighrate(86–100%) of monomi- common bacteria (49%) found in wound infections crobial wound infection was reported from different followed by E. coli (25.9%), Klebsiella spp. (9.5%), P. aer- states of India [28, 29]. uginosa (8.6%), Proteus spp. (4%) and Acinetobacter Among different age groups, the prevalence of wound (2.7%) spp. S. aureus is the most common strain (25%) infections was highest among age group ≤10 years as a commensal organism of human skin and nasal pas- (82.1%) followed by age group 70–80 years (77.8%). This sage. Hence, most frequent isolation of S. aureus from is in agreement with study carried by Lakhey et al. where pus specimens might also be due to contamination of higher prevalence of wound infection was reported among collected specimens with skin normal flora [31]. Contri- patients of age group 60–80 years [20]. Similarly, in a study bution of multidrug resistant Acinetobacter spp. to noso- done by Mohammedaman et al., [5] in South Ethiopia, comial infections has increased over the past decade, 87.5% wound infection was in patients with age ≥ 60 years. and many outbreaks involving this bacterium have been Since old individuals and children have weak immunity, reported worldwide [32]. Table 6 Antibiogram result of isolates Isolated organisms Antibiogram Total MDR [N(%)] No. (%) of resistance R2 R3 R4 R5 Gram positive S. aureus (n = 66) 20 (30.3) 18 (27.3) 3 (4.5) 4 (6.1) 45 (68.2) CoNS (n = 9) 4 (44.4) 1 (11.1) 2 (22.2) 0 7 (77.7) Enterococcus spp. (n = 5) 3 (60) 0 1 (20) 0 4 (80) Total (n = 80) 27 (33.75) 19 (23.75) 6 (7.5) 4 (5) 56 (70) Gram negative E. coli (n = 10) 6 (60) 1 (10) 0 1 (10) 8 (80) P. aeruginosa (n = 5) 2 (40) 1 (20) 1 (20) 0 4 (80) Acinetobacter spp. (n = 6) 2 (33.3) 1 (16.7) 1 (16.7) 0 4 (66.7) C. freundii (n = 3) 2 (66.7) 0 0 0 2 (66.7) K. pneumoniae (n = 6) 2 (33.3) 1 (16.7) 0 2 (33.3) 5 (83.3) P. vulgaris (n = 2) 1 (50) 0 0 0 1 (50) P. mirabilis (n = 1) 1 (50) 0 0 0 1 (50) Total (n = 33) 10 (30.3) 3 (9.1) 2 (6.1) 2 (6.1) 17 (51.5) R2-R5 number of antibiotics class where an isolate was resistant Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 8 of 10 Shrestha et al., [21] have found that 85% of S. aureus iso- respectively. The prevalence rate may vary based on lates were sensitive to ciprofloxacin, 83% and 82% were sample collection method, site of sample collection, mi- sensitive to cephalexin and cotrimoxazole respectively. In crobial detection technique, antimicrobial agents used, this study, 60.6% of Staphylococci isolates were resistant to and geographical location. In this study, 68.2% of S. aur- cefoxitin. S. aureus which was resistant to cefoxitin anti- eus and 80% of E. coli isolates were MDR strains. The biotic was reported as MRSA species. Rajbhandari et al., highest rate (83.3%) of MDR was observed in K. pneu- [36] have also reported 61.6% of MRSA prevalence in moniae. This finding is in agreement with the study con- wound infection. The second common isolate of this study ducted in South-West Ethiopia by Mohammedaman et was E. coli where 80%, 60%, 50% and 40% of the isolates al. [5]. Most of the Gram negative isolates were resistant were susceptible to gentamycin, ciprofloxacin, cefotaxime to ampicillin (86.4%) and cefazolin (77.3%) while 88.6% and cotrimoxazole respectively. All the isolates of E. coli and 60% of Gram positive bacteria were resistant to (100%) were resistant to ampicillin where 30% and 20% ampicillin and amikacin respectively. In Nepal, oral ad- were resistant to ceftriaxone and cefazolin respectively. ministration of antibiotics is common practice which Similarly, 60% and 40% of E. coli isolates were susceptible may reduce absorption of antibiotics by blood stream. to ciprofloxacin and cotrimoxazole respectively. This study Long term use of antibiotics via oral route could con- showed low sensitivity rate as compared to other studies tribute to bacteria developing resistance. [33]. Hence, increased antimicrobial resistant rate of E. coli Wound infection is a burning public health issue espe- depicts its important role in nosocomial infections. cially in developing countries. Severe wound infection can All the isolates of P. aeruginosa (100%) were sensitive to cause great loss including higher rate of morbidity and amikacin, tobramycin and imipenem while 80% and 60% mortality; longer hospital stays, delay in wound healing, were sensitive to ciprofloxacin and piperacillin respect- increase economic burden and increase discomfort which ively. Only 40% of the P. aeruginosa were susceptible to in turn increases disease burden significantly. Wound in- the antibiotic ceftazidime. In a study conducted by fection is being a common nosocomial infections which Shrestha et al., [21] 93% of isolates were sensitive to ami- accounts for 0–80% of patient’s mortality [35, 36]. kacin and 66.7% of isolates were sensitive to ciprofloxacin. Modernization in control and prevention of infections Our finding in this context is similar with other results has not completely controlled wound infection due to in- where P. aeruginosa isolated from pus samples has shown creasing problem of antimicrobial resistance [37]. As com- least resistance to ciprofloxacin (6.2–24%) [34]. More pared to previous studies, antimicrobial resistance pattern prevalence of antimicrobial resistant P. aeruginosa in is increasing at high rate. Multiple factors may contribute wound infection is being a challenging issue especially in to rapid development of antimicrobial resistance by patho- resource limited countries [26]. gens including misuse, overuse, and underuse of antimi- K. pneumoniae was most sensitive to meropenem crobials by both clinicians and patients. In Nepal, people (83.3%) and 66.7% of K. pneumoniae isolates were equally purchase antimicrobials without physician’sprescription, resistant to gentamycin, ciprofloxacin, and amikacin which is a common practice. This leads to misuse of anti- where 50% of isolated K. pneumoniae were resistant to microbials that contributes to the emergence and spread cotrimoxazole and ceftriaxone. In a study reported by of antimicrobial resistant strain. MRSA and ESBL produ- Mohammedaman et al., [5]35.7% of K. pneumoniae were cing bacteria are creating a serious problem in wound resistant to ciprofloxacin and doxycycline. Furthermore, treatment in different parts of the country. Rajput et al., [24] had reported that 45.5% and 80% of K. pneumoniae strains were resistant to ciprofloxacin and cotrimoxazole respectively. All isolates (100%) of P. vul- Conclusion garis were susceptible to amikacin, and cefotaxime but In this study, the most common isolate was S. aureus in 100% of P. vulgaris isolates were resistant to ampicillin pus specimens. Among S. aureus isolates, 60.6% were and cefazolin while 50% of isolated P. vulgaris were resist- MRSA strains, whereas 40% of K. pneumoniae and ant to ciprofloxacin and cotrimoxazole. All isolates (100%) 33.3% C. freundii were ESBL producer followed by E. of P. mirabilis were sensitive to ciprofloxacin, amikacin coli (25%). Eighty percent (80%) of E. coli, P. aeruginosa, and cefotaxime whereas 100% were resistant to ampicillin, and 68.2% of S. aureus were MDR strains. This study cotrimoxazole and cefazolin. This result is comparable emphasizes the importance of strict nosocomial infec- with study carried by Bhatta et al. [20]. tion control strategies and careful prescription of antimi- Among Enterobacteriaceae isolates, 25% of E. coli, 40% crobials should be implemented by the health care of K. pneumoniae and 33.3% of C. freundii were ESBL centres. It should be mandatory to screen out ESBL, producer. But none of the Proteus species were ESBL MRSA, and MDR pathogens and regular monitoring of producer. Chander et al., [35] have reported 13.51% and their antimicrobial susceptibility pattern for prevention 16.55% of E. coli and K. pneumoniae as ESBL producer and control of wound infections. Early reporting of drug Upreti et al. Antimicrobial Resistance and Infection Control (2018) 7:121 Page 9 of 10 resistant pathogens and evidence-based treatment algo- Received: 31 July 2018 Accepted: 17 September 2018 rithm can control the wound infections. Research on AMR is in its infancy stage in Nepal, but it is paramount to establish surveillance programs to reduce burden of References 1. 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Journal

Antimicrobial Resistance and Infection ControlSpringer Journals

Published: Oct 8, 2018

Keywords: Wound infection; Methicillin resistant Staphylococcus aureus; ESBL; Multidrug resistant; Nepal

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