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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 5  |  Page : 441-446  

Bacteriological profile of surgical site infections and its resistogram in Sangli district, Maharashtra


Department of Microbiology, Bharati Vidhyapeeth Deemed to be University Medical College and Hospital, Sangli, Maharashtra, India

Date of Submission31-Oct-2019
Date of Decision14-Dec-2019
Date of Acceptance17-Jan-2020
Date of Web Publication7-Sep-2020

Correspondence Address:
Girish S Sharnathe
A/P-Vita, Sangli - 415 311, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_298_19

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  Abstract 


Introduction: Surgical site infection (SSI) is one of the most common hospitals acquired infection. The present study describes resistogram of bacterial pathogens in SSIs in the hospitals in and around Sangli, Maharashtra, India. Materials and Methods: The resistogram pattern was studied by modified Kirby-Bauer disc diffusion method. Results: A total of 1491 pus samples from patients clinically diagnosed of SSIs were processed and 911 isolates were obtained. The most common Gram-positive isolates were Staphylococcus aureus(53.92%), coagulase-negative Staphylococci (31.17%), Enterococcus (10.58%), and Streptococcus pyogens (4.31%); while Gram-negative isolates were Escherichia coli (33.16%), Klebsiella spp. (28.92%), Citrobacter species (4.98%), Pseudomonas aeruginosa (12.96%), Acinetobacter species (1.99%), Proteus mirabilis (10.97%), and Proteus vulgaris (6.98%). The frequency of methicillin-resistant S. aureus (MRSA) was 28% whereas the frequency of methicillin sensitive S. aureus was 72%. The MRSA showed multidrug resistance pattern. Conclusion: Twenty-eight percent are MRSA which showed multidrug resistance pattern. While most of the Gram-positive isolates were resistance toward the amoxicillin/clavulanate, gentamicin, and ceftriaxone. Most of the Gram-negative isolates were resistant to ampicillin, ciprofloxacin and ceftriaxone.

Keywords: Antibiotics, methicillin resistant Staphylococcus aureus, methicillin sensitive Staphylococcus aureus, resistogram, surgical site infections


How to cite this article:
Sharnathe GS, Gadgil S A. Bacteriological profile of surgical site infections and its resistogram in Sangli district, Maharashtra. Med J DY Patil Vidyapeeth 2020;13:441-6

How to cite this URL:
Sharnathe GS, Gadgil S A. Bacteriological profile of surgical site infections and its resistogram in Sangli district, Maharashtra. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Sep 25];13:441-6. Available from: http://www.mjdrdypv.org/text.asp?2020/13/5/441/294361




  Introduction Top


Surgical site infection (SSI) may be defined as “invasion and multiplication of microorganisms in body tissue which may result in local cellular injury. This may be due to competitive metabolism, toxins, intracellular replication, or antigen antibody response.”[1] Its also defined as an infection occurring within 30 days after a surgical procedure and affecting either incision or deep tissues at the operation site. These infections may be superficial or deep incision infection or infections involving organ or body space and are associated with increased morbidity, mortality, prolonged hospital stay, and increased economic costs for patient care.[1],[2]

SSI is the third most frequently reported nosocomial infection, accounting for 14%–16% of all nosocomial infections.[3] A plethora of microorganisms with different antimicrobial susceptibility pattern has been identified as the causative agents of SSIs which vary from time to time, hospital to hospital, and with the type of surgical procedure.[4] SSIs are consequence of a summation of several factors such as number of bacteria introduced into the wound during the procedure, the virulence of the organisms, the microenvironment of each wound, and the integrity of the patient's host defense mechanism. Factors intrinsic to the patient, as well as those related to the type and circumstances of surgery also affect the incidence of infection.[5] Other factors associated with SSI are duration of prehospitalization, age and physical status of the patient, administration of prophylactic antibiotics, duration of surgery, tissue handling, and use of drains.[6],[7],[8],[9]

The development of antimicrobial drug resistant pathogens occur as a result of complex interactions, which favor the emergence, persistence, and increased transmission of these resistant bacterial strains.[10],[11] Widespread and inappropriate use of antibiotics has been shown to increase the development of antimicrobial resistant pathogens.[11]

There have been limited data regarding the magnitude of SSIs due to antimicrobial resistant pathogens as well as their resistance pattern, in various surgical hospitals of Sangli district in Maharashtra. This gap makes difficulty for the clinician in choosing empirical therapy for the patient. Advances in the treatment of diseases have led to the significant increase in diverse surgical interventions. In parallel to this, the magnitude of SSIs, use of antimicrobial microbial prescriptions, and emergence of antibiotic-resistant bacterial strains are likely to increase day-by-day.

Therefore, the present study was undertaken to investigate the antimicrobial resistant pattern of pathogens from the SSIs of patients from the surgical hospitals of the study area. It is helpful for the better understanding of the spectrum of pathogens as well as their resistance pattern for prompt management of patients.


  Materials and Methods Top


The study was approved by the Institutional Ethical Committee of Bharti Vidyapeeth Medical College, Sangli vide letter number: BVDUMandH/Sangli/IEC/Dissertation 2015-16/133 dated August 15, 2015.

The study was carried out between April 2017 and January 2019 in various surgical hospitals in and around Sangli, Maharashtra, India. A total number of 28 hospitals including 9 from urban areas and 19 from rural areas were included.

Study Population: A patients with postoperative wound infections in the general surgery, obstetrics/gynecology, and orthopedic hospitals in and around Sangli were considered for the study. A total number of 1491 samples were collected from various surgical hospitals of urban and rural locality.

IEC No. BVDUMandH/Sangli/IEC/Dissertation 2015-16/133 Date August 15, 2015.

Inclusion criteria

  1. Patients of all age groups except neonates
  2. Patients of either sex.
  3. Cases of clean and clean contaminated surgeries.
  4. The presence of postoperative SSIs
  5. Patents who have given written consent.


Exclusion criteria

  1. Infections occurring 30 days after operation if no implant is in place
  2. Burn injuries and donor sites of split skin grafts
  3. Procedures in which healthy skin was not incised such as opening abscess
  4. Patients undergoing re-operations.


Sample collection

The specimens were collected aseptically on the 1st day when patients present with clinical evidence of infection (purulent drainage from incision or drain) before the wound was cleaned with antiseptic. Using sterile cotton wool swabs and sterile container, the pus samples were obtained from surgical site without contaminating with skin commensals. The samples from nearby hospitals were immediately brought to research laboratory and processed. The samples from rural and public health centers with long distance were transported through in sterile saline and Stuart transport media to the laboratory within 2 h.

Sample processing

Specimens were processed and tested in the Department of Microbiology, Bharati Vidyapeeth Deemed University Medical College and Hospital, Sangli. Two swabs of each sample collected, one was processed for smear on clean glass slide and stained by Gram's staining for screening pus cells, type of organism, morphology, and arrangement. The second swab was inoculated on nutrient agar, blood agar, and MacConkey's agar by rolling the swab over the agar and streaking from primary inoculums using a sterile bacteriological loop. The swab was also be inoculated in nutrient broth. Similar procedure was followed for the sample collected in the sterile container. The plates were incubated at 37°C for 24 h and observed for any visible growth. If there is no growth after 24 h, the subcultures were done from nutrient broth and primary plates were further incubated for another 24 h and observed for the growth. The isolates were identified by following standard identification procedures such as colony morphology, Gram staining, motility, enzymatic, and other biochemical tests.

Antimicrobial susceptibility testing

A standard disk diffusion technique for antimicrobial susceptibility testing was performed as per the guidelines of clinical and laboratory standard institute. It was done by Kirby-Bauer disc diffusion method. The antibiotic discs used were – ampicillin, ciprofloxacin, oxacillin, cefoxitin, cefotaxime, cotrimoxazole, cefepime, ceftazidime, ceftazidime/clavulanicacid, amikacin, imipenem, gentamicin, Vancomycin, amoxicillin/clavulanic acid, ceftriaxone, meropenem, erythromycin, clindamycin, ofloxacin, chloramphenicol, linezolid, tetracycline, piperacillin/tazobactam, tobramycin.


  Results Top


A total of 1491 samples were collected from various surgical hospitals of urban and rural locality. Out of them nine hospitals were from urban area while nineteen hospitals were from rural area [Table 1].
Table 1: Number of hospitals included in the study

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The patients admitted had undergone surgical procedures during the study. The age group of patients was 5–78 years and the number of male patients was 686 (46%) while the number of female patients was 805 (54%). Among the total of 1491 samples, 865 (58.01%) were positive for the cultures from which, the total number of 911 isolates were obtained. Among the 865 positive samples, 830 samples represented only a single isolate, 24 were with two isolates whereas11 were with three isolates.

Among the 911 isolates, 510 (55.98%) were Gram-positive and 401 (44.02%) were Gram-negative. The isolates were further identified on the basis of their phenotypic properties [Table 2].
Table 2: Isolates recovered from the samples

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Out of 510 Gram-positive isolates, 275 (53.92%) were Staphylococcus aureus, followed by 159 (31.17%) coagulase-negative Staphylococcus (CONS), 54 (10.58%) Enterococcus spp., and 22 (4.31%) Streptococcus pyogens. Among the 275 S. aureus isolates, 77 (28%) were methicillin-resistant S. aureus (MRSA) while 198 (72%) were methicillin sensitive S. aureus (MSSA).

The distribution of 401 (44.02%) Gram-negative bacteria was  Escherichia More Details coli 133 (33.16%), Klebsiella spp. 116 (28.92%), Citrobacter spp. 20 (4.98%), followed by Pseudomonas aeruginosa 52 (12.96%), Acinetobacter spp. 8 (1.99%), Proteus mirabilis 44 (10.97%), and Proteus vulgaris 28 (6.98%).

The antimicrobial resistance profile of the Gram-positive and Gram-negative isolates is as given in [Table 3] and [Table 4], respectively. As shown in [Table 3], all the MRSA isolates were found to be sensitive to the tigecycline, 76 were sensitive to vancomycin while 75 were sensitive to linezolid. This indicates that MRSA isolates are having least resistance pattern toward tigecycline, vancomycin, and linezolid, respectively, while high degree of resistance toward the amoxicillin/clavulanate, gentamicin, and ceftriaxone. Among the other isolates, high degree of resistance was to the amoxicillin/clavulanate, ceftriaxone, and tetracycline in MSSA isolates; to tetracycline, amoxicillin/clavulanate, and ciprofloxacin in CONS; to amoxicillin/clavulanate, ceftriaxone, gentamicin, and tetracycline in Enterococcus spp. and to clindamycin, erythromycin, and ceftriaxone in S. pyogens. All of the isolates were highly sensitive to the tigecycline, vancomycin, and linezolid.
Table 3: Antibiotic resistance pattern of Gram-positive isolates

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Table 4: Antibiotic resistance pattern of Gram-negative isolates

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As regard to the Gram-negative isolates, as shown in [Table 4], E. coli isolates were highly resistant to ampicillin, ciprofloxacin, and ceftriaxone. The species of Klebsiella were resistant to ampicillin, cotrimoxazole, and ceftazidime. Citrobacter species were resistant to ampicillin, cefotaxime, cotrimoxazole, and amoxicillin/clavulanic acid. P. aeruginosa isolates were resistant to the ampicillin, gentamicin, and cotrimoxazole. Acinetobacter spp. were resistant to the ciprofloxacin, cotrimoxazole, ceftriaxone, and ampicillin; P. mirabilis were resistant to the ampicillin, cotrimoxazole, and ceftazidime while P. vulgaris were resistant to ampicillin; ceftazidime, ciprofloxacin, and gentamicin. Most of the isolates were sensitive to the piperacillin/tazobactam, meropenem, imipenem, and ceftazidime/clavulanic acid.


  Discussion Top


The study by MGM Medical College and Hospital, Mumbai, reported 73 (71.5%) positive growth out of 102 samples analyzed which is comparatively more than our results.[12]

Literature study also reveals that there is a great variation among the Gram-positive and Gram-negative organisms associated with SSIs in the different geographical areas. In most SSIs, the pathogens originate from endogenous flora of the patient's skin, mucous membranes, or hollow viscera. The most common isolates were S. aureus, member of enterobacteriaceae, CONS. Although the pathogens isolated depend on the surgical procedure involved, recent reports indicate increasing proportion of Gram-positive organisms than Gram-negative organisms associated with SSIs. In our study, majority of bacteria were Gram-positive (55.98%) as compared to Gram-negative (44.02%), and the predominant isolate was S. aureus.[1]

A study at Government Hospital, Tiruchengode, in South India, found that among the 78 isolates, 28% were S. aureus, 20% were Escherichia coli, 8% were Pseudomonas spp. 5% were Klebsiella spp. 1% were Proteus spp. 12% were CONS and 20% were others.[13]

A similar kind of study on SSIs at NRS Medical College at Kolkata, West Bengal, and reported that out of 3003 positive samples, 34.93% were S. aureus, followed by 20.34% E. coli, 18.08% Klebsiella spp., 7.99% Pseudomonas spp., 7.49% Acinetobacter spp., 4.39% Enterococcus spp. 3.16% CONS, 1.73% Proteus spp., 1.29% Citrobacter spp., and 0.26% Enterobacter spp. Among the S. aureus, 25.45%. were MRSA and they were found to be 100% sensitive to linezolid and tigecycline, followed by 92.51% fucidin, 88.39% mupirocin, 75.66% levofloxacin, and 72.28% doxycycline. Vancomycin-resistant strains were not detected. They were showing high-degree resistance to clarithromycin, cotrimoxazole, and gentamicin. The MRSA strains were more resistant than MSSA strains to all the antibiotics used for the study, except for vancomycin, linezolid, and tigecycline.[14] Similar observations were obtained at Gwalior and Karnataka.[15],[16] Incidence of MRSA in the range of 15.7%–63.5% in India has been reported.[17] MRSA is now responsible for 30% or more of all serious infections.[18] The variation in the incidence may be due to the pre- and post-operative antibiotic policy.

A study on SSIs at South Gujarat observed that most of the Gram-negative isolates were sensitive to imipenem and meropenem which was followed by piperacillin-tazobactam while Gram-positive isolates were more sensitive to the levofloxacin, linezolid, and vancomycin. E. coli was 100% sensitive to imipenem, meropenem, levofloxacin, ofloxacin and 50% to piperacillin/tazobactam, amikacin gentamicin, kanamycin, and fully resistant to ampicillin, cefazolin, and cefaclor. This study is comparable with our investigations.[19] Neelesh et al. reported that the Gram negative organisms were 100% sensitive to imipenem followed by 99.07% to piperacillin/tazobactam, 69.44% to ceftazidine, and 65.74% to amikacin.[20]

Most of the E. coli isolates were multidrug resistance. More than 75% strains were resistant to cephalexin, cotrimoxazole, nalidixic acid, and tetracycline and 96% strains were resistant to ampicillin. The most drug against E. coli was imipenem (100% sensitive).[21] The results in our study also are very close to these observations.


  Conclusion Top


The present study reveals that most of the pathogens associated with the SSIs in the study area are Gram positive and predominantly S. aureus. Among these, 28% are MRSA which showed multidrug resistance pattern. These isolates were showing least resistance pattern toward tigecycline, vancomycin, and linezolid while high degree of resistance toward the amoxicillin/clavulanate, gentamicin, and ceftriaxone. Further, it was found that more number of E. coli isolates were resistant to ampicillin, ciprofloxacin, and ceftriaxone. This resistogram of bacterial pathogens from SSIs in the hospitals in and around Sangli, Maharashtra, indicates the increased multidrug resistance of pathogens and will be useful for clinicians in deciding the line of treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999;27:97-132.  Back to cited text no. 1
    
2.
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Culbertson WR, Altemeier WA, Gonzalez LL, Hill EO. Studies on the epidemiology of postoperative infection of clean operative wounds. Ann Surg 1961;154:599-610.  Back to cited text no. 4
    
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Cruse PJ. Surgical wound infection. In: Gorbach SL, Bartlett GC, Blacklow NR, editors. Infectious Diseases. Philadelphia, London, Toronto, Montreal, Sydney, Tokyo: W.B. Saunders Company, Harcourt Brace Jovanovich Inc.; 1992. p. 738-64.  Back to cited text no. 6
    
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Hernandez K, Ramos E, Seas C, Henostroza G, Gotuzzo E. Incidence of and risk factors for surgical-site infections in a Peruvian hospital. Infect Control Hosp Epidemiol 2005;26:473-7.  Back to cited text no. 8
    
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Chadli M, Rtabi N, Alkandry S, Koek JL, Achour A, Buisson Y, et al. Incidence of surgical wound infections a prospective study in the Rabat Mohamed-V Military Hospital, Morocco. Med Mal Infect 2005;35:218-22.  Back to cited text no. 9
    
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11.
Cohen ML. Epidemiology of drug resistance: Implications for a post-antimicrobial era. Science 1992;257:1050-5.  Back to cited text no. 11
    
12.
Insan NG, Payal N, Singh M, Yadav A, Choudhary BL, Srivastava A. Post operative wound infection: Bacteriology and antibiotic sensitivity pattern. Int J Cur Res Rev 2013;05:74-9.  Back to cited text no. 12
    
13.
Shanthi J, Shakar T, Balagurunathan R. The scenario of post operative wound infection from a Government Hospital in South India. J Microbiol Biotech Res 2012;02:396-401.  Back to cited text no. 13
    
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Bhattacharya S, Pal K, Jain S, Chatterjee SS, Konar J. Surgical site infection by methicillin resistant Staphylococcus aureus – on decline? J Clin Diagn Res 2016;10:DC32-6.  Back to cited text no. 14
    
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Ranjan KP, Ranjan N, Gandhi S. Surgical sites infections with special reference to methicillin resistant Staphylococcus aureus: An experience from tertiary care referral hospital in North India. Int J Res Med Sci 2013;1:108-11.  Back to cited text no. 15
    
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Krishna S, Divya P, Shafiyabi S. Post operative surgical wound infections with special reference to methicillin resistant Staphylococcus aureus (2015): An experience from VIMS Hospital, Ballari. J Biosci Tech 2015;3:697-702.  Back to cited text no. 16
    
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Negi V, Pal S, Juyal D, Sharma MK, Sharma N. Bacteriological profile of surgical site infections and their antibiogram: A study from resource constrained rural setting of Uttarakhand State, India. J Clin Dign Res 2015;9:17-20.  Back to cited text no. 17
    
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Anupurba S, Sen MR, Nath G, Sharma BM, Gulati AK, Mohapatra TM. Prevalence of methicillin resistant Staphylococcus aureus in a tertiary care referral hospital in Eastern Uttar Pradesh. Indian J Med Microbiol 2003:2:49-51.  Back to cited text no. 18
    
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20.
Neelesh RN, Rama NK, Sharadadevi MY, Renushri BV, Nagaraj ER. Antibiotic susceptibility pattern of bacterial isolates causing surgical site infection. Natl J Basic Med Sci 2012;3:154-8.  Back to cited text no. 20
    
21.
Murshed M, Shahnaz S, Malek MA. Detection of resistant gene marker intl 1 and antimicrobial resistance pattern of E. coli isolated from surgical site wound infection in Holi family Red Cresent Medical College Hospital. Bangladesh J Med Microbiol 2010;04:19-23.  Back to cited text no. 21
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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