Download original article pseudomonas aeruginosa and its antibiogram from

ORIGINAL ARTICLE
PSEUDOMONAS AERUGINOSA AND ITS ANTIBIOGRAM FROM
CLINICAL ISOLATES IN A TERTIARY TEACHING HOSPITAL FROM
WESTERN MAHARASHTRA, INDIA
Satyajeet K. Pawar1, P. M. Mane2, Ravindra V. Shinde3, H. V. Patil4, S. R. Patil5, G. S. Karande6,
S. T. Mohite7
HOW TO CITE THIS ARTICLE:
Satyajeet K. Pawar, P. M. Mane, Ravindra V. Shinde, H. V. Patil, S. R. Patil, G. S. Karande, S. T. Mohite
“Pseudomonas Aeruginosa and its Antibiogram from Clinical Isolates in a Tertiary Teaching Hospital from
Western Maharashtra, India”. Journal of Evidence Based Medicine and Healthcare; Volume 1, Issue 7,
September 2014; Page: 574-581.
ABSTRACT: BACKGROUND: Pseudomonas aeruginosa is one of the leading causes of
nosocomial as well as community acquired infections. Due to development of multi drug
resistance (MDR), there are many therapeutic failures. The present study was carried out to find
out the susceptibility pattern of the organism in this area. METHODOLOGY: From 2089 clinical
specimens received over a period of six months, a total of 277 P.aeruginosa strains were
identified and minimum inhibitory concentrations for various antibiotics was found out with help
of automated method VITEK 2 (Biomerieux), RESULT: 75.81% P.aeruginosa isolated were MDR.
Proportion of resistant strains varied from 38% to 75% to commonly used antipseudomonal
antimicrobials groups like aminoglycosides, cephalosporins, carbapenems, fluoroquinolones, and
anti-pseudomonal penicillins. Resistance to colistin was only15%. CONCLUSION: P. aeruginosa
were less resistant to β lactam with β lactamase inhibitor combination therapy like cefoperazone
/sulbactam and piperacillin/tazobactam. Colistin was most sensitive antibiotic. Prior information of
susceptibility will be useful to reduce mortality and morbidity caused by P.aeruginosa.
KEYWORDS: P.aeruginosa, Clinical isolates, Multidrug resistant (MDR).
MESHTERMS: p.aeruginosa, antibiogram.
INTRODUCTION: Pseudomonas aeruginosa is one of the stubborn gram negative bacilli isolated
from environment and also from clinical specimens. It is one of the leading causes of hospital
infection.1 It is associated with wide spectrum of infections like bacteremia, wound infection,
secondary meningitis, severe sepsis, ocular and urinary tract infection, chronic suppurative otitis
media, lower respiratory tract infections, cystic fibrosis and pneumonia.2, 3
Major problem with these P.aeruginosa strains isolated from clinical specimens, is
development of drug resistance even against newer antimicrobials.4 This has resulted in isolation
of P.aeruginosa from hospitalized patients which are multidrug resistant (MDR) strain.5Nosocomial
infections caused by such strains are responsible for mortality and morbidity in patients.6With
prior knowledge of susceptibility pattern in particular area, it becomes easy to choose appropriate
antimicrobial against these resistant strains. The present study therefore was carried out to find
out susceptibility pattern of P.aeruginsa in a tertiary teaching hospital in Western Maharashtra,
India.
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 1/ Issue 7 / Sept. 2014.
Page 574
ORIGINAL ARTICLE
MATERIAL AND METHODS:
Study Design: Laboratory based prospective study.
Study Period: From January 2014 to June 2014.
Settings: Study was carried out at Department of Microbiology, Krishna Institute of Medical
Sciences, Karad
Inclusion criteria: P.aeruginosa isolated from different clinical specimens were included in the
study.
Exclusion criteria: Repeat isolate of P.aeruginsa from same patient from repeat specimen was
excluded from study to avoid duplication of isolate.
METHODOLOGY: A total of 2891 clinical specimens were received in this period. Specimens
were pus, endotracheal secretions, sputum, urine, stool, cerebrospinal fluid, blood, and body
fluids like ascitic fluid, peritoneal fluid, pleural fluid and other specimens like catheter tips,
kneeaspirate, corneal scrapings etc. Processing of the specimens were done on blood agar,
chocolate agar, and MacConkey’s agar.7 Bacterial colonies were identified by VITEK 2 compact
(Biomerieux) automation system and antimicrobial susceptibility testing was done with the same
system to detect MIC. For this antimicrobials used in the panel were amikacin (An), gentamicin
(G), ciprofloxacin (Cip), levofloxacin (LEV), ceftazidime (CAZ), cefepime (SFP), imipenem (IPM),
meropenem (MEM), doripenem (DOR), colistin (CS), minocycline (MNO), tigecycline (TGC),
trimethoprim/sulfamethoxazole (SXT), ticarcillin/clavulanic Acid (TCC), piperacillin/tazobactam
(TZP).
Interpretation of test was done as per CLSI (2013) guidelines.8 Quality control of the test
was done by standard ATCC strain P. aeruginosa 27853.8 All 277 P.aeruginsa strains, isolated
during study period were included for data analysis in the study.
RESULTS: Of the total 1370 bacteria, isolated during the study period, 1104 were gram negative
bacilli. P.aeruginosa 277 (25%) were the third most isolates among gram negative bacilli. (Fig. 1)
As shown in Fig. 2, among all specimens, P.aeruginosa were isolated maximum in number (124)
from pus specimens. Most number of P.aeruginosa isolated from various specimens were
resistant to different antimicrobials tested as shown in Table 1.Proportion of resistant strains
varied from 38% to 75% as shown in Table 2 to commonly used anti-pseudomonal
antimicrobials. Uncommon drug like colistin did showed sensitivity up to 84.84%. Around 70% of
strains were resistant to aminoglycosides, fluoroquinolones, and cephems. What was alarming
was, carbapenems showed resistant from 56.31% to 62.81%. All strains were resistant to at least
one antibiotic from minimum one antimicrobial group. (Table 3) 75.81% of strains were MDR that
is resistant to at least one antibiotic from minimum 3 or more antimicrobial groups.
DISCUSSION: Multidrug resistant P.aeruginosa has many times been associated with treatment
failure. This is seen more commonly in nosocomial infections. In the present study, a total 277
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 1/ Issue 7 / Sept. 2014.
Page 575
ORIGINAL ARTICLE
P.aeruginosa strains were isolated from various clinical specimens. Isolation rate was 20.21% of
all 1370 clinical isolates. Almost similar, 17.05% of isolation rate was observed by Chander A.9
Pus was predominant specimen, accounting for 44.76% of all specimens.Senthamarai S. et al in
their study isolated 47.11% P.aeruginosa from pus specimens which is fairly comparable with our
study.10
Rising trends of resistance has been observed for P.aeruginosa from various clinical
isolates all over world.9.11In our study, more than half of the strains isolated from all types of
clinical specimens were resistant to antimicrobials tested (Table 1). Resistance to
aminoglycosides, amikaicin and gentamicin was 62.81% and 72.74%. Similar findings were
obtained by Mohanasoundaram KM12 and Arora D et al.13 Higher resistance level to quinolones were
comparable with findings of Mohanasoundaram KM,12 Chander A9 and Ahmed SM.14 Ceftazidime
and cefepime showed resistance of 70.39% and 74.72% respectively. Mohanasoundaram KM12
found it around 63.3% and 72.3% respectively. Similar findings were also obtained in study carried
in Gujarat, India where resistance level was observed up to 75%.15 Higher resistance level to all
these three antimicrobial groups might have been due to overuse of antimicrobials. Also this
hospital being referral centre; many of the patients have already received antimicrobials at private
clinics before being referred. β lactamase production has resulted in development of resistance to
cephalosporins. This was confirmed by combination of β lactam and β lactamase inhibitor drug,
cefoperazone /sulbactam which was resistant to only 37.90% of strains only.15
Carbapenem group showed threatening level of resistance, although it was a newer
antimicrobial group in use. Imepenem and doripenem showed 58.48% and 56.31% of resistance
respectively while for meropenem it was 62.81%. In a Malyasian study, 74.74% of P.aeruginosa
were resistant to imepenem.16 The higher resistance level in the present study might have been
due to metalloβ lactamase production and indiscriminate of these antimicrobials in the hospital.
Older antibiotics like colistin, polymixin discovered 50 years ago have become important
focus especially in treatment of multidrug resistant gram negative bacilli (MDRGNB).17,18 Only
15.16% of P.aeruginosa in the study were resistant to colistin. Our findings were consistent with
the Malaysian study in which it was 8%.16 Considering toxicity of colistin, and its reemergence of
these older antibiotics, especially in treatment of MDRGNB, many studies have started collecting
data on its pharmacokinetics and pharmacodynamics.17, 18 Tigecycline and other glycicycline showed
high resistance, as many studies has shown that P.aeruginosa strains have developed efflux pump
mediated resistance to many of these drugs.19
Combination drugs likeTicarcillin/Clavulanic acid (48.01%) and Piperacillin/Tazobactum
(43.32%) were comparatively less resistant to other antibiotics tested which is explained on the
basis of inhibitionof β lactamase by β lactamase inhibitor.9,10,15 Combination therapy has been
suggested by many authors.12, 20 Also antibiogram of P.aeruginosa varies considerably from place,
states to countries across the world.9,10,13,16 The incidence of MDR (75.81%)was on higher side
suggestive of misuse of antibiotics. In India MDR percentage for P.aeruginsa ranges from 20.69%
reported by Chander A.et al,9 to 91.6% reported by Panranjothi S.et al.,21
CONCLUSION: Combination therapy like β lactam with β lactamase inhibitor will be more
appropriate drug combination. Colistin may become one of the leading drug of choice in multi and
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 1/ Issue 7 / Sept. 2014.
Page 576
ORIGINAL ARTICLE
pandrug resistant P.aeruginosa. Also such studies will help clinicians to formulate appropriate
antibiotic policy to implement in every tertiary care hospital.
REFERENCES:
1. Prashanth K, Singh S K, Kanungo R, Sharma S, Shashikala P, Joshi S, Jayachandran S.
Correlations between genotyping and antibiograms of clinical isolates of Pseudomonas
aeruginosa from three different south Indian hospitals. Indian J Med Microbiol 2010; 28:
130-137.
2. Navon-Venezia S, Ben-Ami R, Carmeli Y. Update on Pseudomonas aeruginosa and
Acinetobacterbaumannii infections in the healthcare setting. Curr Opin Infect Dis 2005; 18:
306-13.
3. Chaudhary M, PayasiA. Rising Antimicrobial Resistance of Pseudomonas aeruginosa Isolated
from Clinical Specimens in India. J Proteomics Bioinform2013; 6: 005-009.
4. Gad GF, El-Domany RA, Zaki S et al. Characterization of Pseudomonasaeruginosa isolated
from clinical and environmental samples in Minia, Egypt: prevalence, antibiogram and
resistance mechanisms. J Antimicrobial Chemother. 2007; 60 (5): 1010-1017.
5. Tassios PT, Gennimata V, Spaliara-Kalogeropoulou L et al, Multi resistant Pseudomonas
aeruginosa sero group O: 11 out break in an intensive care unit. Clin Microbiol Infect 1997;
3: 621-628.
6. Shenoy S, Baliga S, Saldanha D R, Prashanth H V. Antibiotic sensitivity patterns of
Pseudomonas aeruginosa strains isolated from various clinical specimens. Indian J Med Sci
2002; 56: 427-30.
7. Collee JG, Miles RS, Watt B, Tests for the identification of bacteria, In: Collee JG, Fraser AG,
Marmion BP, Simmons A, Mackie and McCartney Practical Medical Microbiology. 14thEd.
Churchill Livingstone, 1996: 135-144.
8. Clinical and Laboratory Standards Institute. Performance standards for antimicrobial
susceptibility testing; 23rd international supplement. CLSI document M100-S23.Wayne PA:
Clinical and Laboratory Standards Institute; 2013.
9. Chander A, Raza MS, Antimicrobial Susceptibilty Patterns of Pseudomonas aeruginosa Clinical
Isolates at A Tertiary Care Hospital in Kathmandu, Nepal. Asian J Pharm Clin Res.2013; 6 (3):
235-238.
10. Senthamarai S, Suneel Kumar Reddy A, Sivasankari S et al, Resistance Pattern of Pseudomonas
aeruginosa in a Tertiary Care Hospital of Kanchipuram, Tamilnadu, India. J Clin Diagn Res. May
2014; 8(5): DC30–DC32.
11. Orrett FA. Antimicrobial susceptibility survey of Pseudomonas aeruginosastrains isolated from
clinical sources. J Natl Med Assoc 2004; 96(8): 1065-69.
12. Mohanasoundaram KM. Theantibiotic resistance pattern in the clinical isolates of Pseudomon
asaeruginosaina tertiary care hospital; 2008-2010 (A 3 year study). J Clin Diagn Res 2011; 5(3):
491-94.
13. Arora D, Jindal N, Kumar R, Romit. Emerging antibiotic resistance in Pseudomon asaeruginosa.
Int J Pharm Pharm Sci 2011; 3(2): 82-4.
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 1/ Issue 7 / Sept. 2014.
Page 577
ORIGINAL ARTICLE
14. Ahmed SM, Jakribettu RP, Kottakutty S, Arya B, Shakir VPA. Anemerging multi-drug resistant
pathogen in a tertiary care centre in North Kerala. Annals Biol Res 2012; 3(6): 2794-99.
15. Javiya VA, Ghatak SB, Patel KR Patel JA. Antibiotic susceptibility pattern of pseudomonas
aeruginosa in a tertiary care hospital in Gujarat, India, Indian JPharmacol 2008; 40(15): 230234.
16. Al-Kabsi AM, Yusof MYBM, Sekaran SD. Antimicrobial resistance pattern of clinical isolates of
Pseudomonas aeruginosain the University of Malaya Medical Center, Malaysia. Afr J Microbiol Res
2011; 5(29): 5266-72.
17. Li J, Nation RL, Milne RW et al. Evaluation of colistin as an agent against multi-resistant Gramnegative bacteria. Int J Antimicrobial Agents, 2005; 25(1) 11-25.
18. Li J, Nation RL, Turnidge JD et al, Colistin: the re-emerging antibiotic formulti drug-resistant
Gram-negative bacterial infections. The Lancet Infectious Diseases, 2006: 6(9); 589 – 601.
19. Dean CR, Visalli MA, Projan SJ et al, Efflux-Mediated Resistance to Tigecycline (GAR-936) in
Pseudomonas aeruginosa PAO1, Antimicrob. Agents Chemother. 2003: 47 (3); 972-978
20. Chamot E, Boffi El Amari E, Rohner P, Van Delden C. Effectiveness of combination antimicrobial
therapy for Pseudomonas aeruginosa bacteremia. Antimicrob Agents Chemother. 2003; 47(9):
2756-64.
21. Paranjothi S, Dheepa R. Screening for multidrug resistance bacteria Pseudomonas aeruginosa in
hospitalized patients in Hosur, Krishnagiri (dt) International Journal of Pharma and Biosciences.
2010; Vol.1 (Issue-3).
Fig. 1: Distribution of Gram negative bacilli among clinical isolates
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 1/ Issue 7 / Sept. 2014.
Page 578
ORIGINAL ARTICLE
Fig. 2: Distribution of P.aeruginosafrom clinical specimens
Specimen
(N0)
Blood (6)
Body
Fluids(3)
CSF (1)
ETT (70)
Other (14)
Pus (124)
Sputum
(19)
Urine (40)
An
GM
Cip
LEV
CAZ
FEP
SFP
IPM
MEM
DOR
CS
MNO
TGC
SXT
TCC
TZP
5
5
5
4
4
5
4
2
3
3
4
4
4
5
3
3
2
2
1
1
1
2
1
2
2
2
0
2
2
2
2
2
1
40
8
84
1
46
10
91
1
44
10
90
1
46
11
94
1
51
10
91
1
49
9
83
1
47
9
9
1
47
8
70
1
50
9
74
1
38
8
72
0
0
5
22
1
65
13
13
1
59
13
13
1
66
13
13
1
61
11
11
1
55
10
10
6
7
7
8
7
7
5
7
9
8
1
16
16
17
12
8
28
31
34
35
30
28
29
25
26
24
10
33
29
34
32
31
Table 1: Antibiogram showing number of strains of P.aeruginosa isolated & their resistance pattern
An – Amikacin, G-Gentamicin, Cip-Ciprofloxacin, LEV-Levofloxacin, CAZ-Ceftazidime, SFPCefepime, IPM-Imipenem, MEM-Meropenem, DOR-Doripenem, CS-Colistin, MNO-Minocycline,
TGC-Tigecycline, SXT-Trimethoprim/Sulfamethoxazole, TCC-Ticarcillin/Clavulanic Acid, TZPPiperacillin/Tazobactam
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 1/ Issue 7 / Sept. 2014.
Page 579
ORIGINAL ARTICLE
Antimicrobial
Resistant (%) Sensitive (%)
Amikacin
174 (62.81)
103 (37.19)
Gentamicin
207 (74.72)
70 (25.28)
Ciprofloxacin
192 (69.31)
85 (30.69)
Levofloxacin
200 (72.20)
77 (27.80)
Ceftazidime
195 (70.39
82 (29.01)
Cefepime
207 (74.72)
70 (25.28)
Cefoperazone/Sulbactam
105 (37.90)
172 (62.10)
Imipenem
162 (58.48)
115 (41.52)
Meropenem
174 (62.81)
103 (37.19)
Doripenem
156 (56.31)
121 (43.69)
Colistin
42 (15.16)
235 (84.84)
Minocycline
147 (53.06)
130 (46.94)
Tigecycline
137 (49.45)
140 (50.55)
Trimethoprim/Sulfamethoxazole
151 (54.51)
126 (45.49)
Ticarcillin/Clavulanic Acid
133 (48.01)
144 (51.99)
Piperacillin/Tazobactam
120 (43.32)
157 (56.68)
Table 2: Total number of P.aeruginosa strains sensitive
and resistant to various antibiotics
P.aeruginosa isolates
n=277 (%)
0 (0.00)
7 (2.52)
60 (21.66)
210 (75.81)
Resistance to no. of classes
of antimicrobials tested
0
1
2
>=3
Table 3: Numerical antimicrobial resistance pattern of P.aeruginosa
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 1/ Issue 7 / Sept. 2014.
Page 580
ORIGINAL ARTICLE
AUTHORS:
1. Satyajeet K. Pawar
2. P. M. Mane
3. Ravindra V. Shinde
4. H. V. Patil
5. S. R. Patil
6. G. S. Karande
7. S. T. Mohite
PARTICULARS OF CONTRIBUTORS:
1. Associate Professor, Department of
Microbiology, Krishna Institute of Medical
Sciences, Karad, Maharashtra, India.
2. Assistant Professor, Department of
Microbiology, Krishna Institute of Medical
Sciences, Karad, Maharashtra, India.
3. Associate Professor, Department of
Microbiology, Krishna Institute of Medical
Sciences, Karad, Maharashtra, India.
4. Assistant Professor, Department of
Microbiology, Krishna Institute of Medical
Sciences, Karad, Maharashtra, India.
5. Professor, Department of Microbiology,
Krishna Institute of Medical Sciences,
Karad, Maharashtra, India.
6. Professor and Head, Department of
Microbiology, Krishna Institute of Medical
Sciences, Karad, Maharashtra, India.
7. Principal and Professor, Department of
Microbiology, Krishna Institute of Medical
Sciences, Karad, Maharashtra, India.
NAME ADDRESS EMAIL ID OF THE
CORRESPONDING AUTHOR:
Dr. Satyajeet K. Pawar,
Associate Professor,
Department of Microbiology,
Krishna Institute of Medical Sciences,
Karad - 415110, Maharashtra, India.
E-mail: [email protected]
Date
Date
Date
Date
of
of
of
of
Submission: 31/07/2014.
Peer Review: 01/08/2014.
Acceptance: 07/08/2014.
Publishing: 12/08/2014.
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 1/ Issue 7 / Sept. 2014.
Page 581