Hospital Management: Bacterial Infection

Hospital Management: Bacterial Infection Prevalence of bacterial infection on burned patients, in Shafieh hospital, Zanjan, Iran April 2009

Authors: Rahim Mosahab, PhD Candidate, School of Management, Universiti Sains Malaysia (USM), Pulau Pinang, Malaysia ([email protected]) Abolfath Shojaie Arani, Assistant Professor, Dep. of Microbiology, University of

Iran

Medical Sciences, Tehran, Iran ([email protected]) Abstract A retrospective study of bacterial surveillance from wound swab, urine and blood cultures of burned patients hospitalized in burn ward in Zanjan, Iran was performed on 91 patients over 12 months, and 60 gr. Of negative and positive isolated bacteria were found. Pseudomonas aeruginosa was the most :frequently isolated organism (41.5%). We were able to isolate 35 other different bacteria as follows 1. E.coli, 10 clinical samples (16.6%) 2. Staphylococcus, 13 clinical samples (21.58%) 3. Enterobacter, 8 clinical samples (13.28%) 4. Citrobacter freundii, 3 clinical samples (4.98%) 5. Klebsiella, one clinical sample (1.66%) Their antibiogram was determined according to standard Kirby disk diffusion method. The antibiogram :results indicated that Most isolated Pseudomonas aeruginosa were sensitive to Amikacin (86%), Cyprofloxacin (75.6%), (1 Gentamicin (54%) and Norfloxacin (21.6%), and were resistant to Ceftazidime tetracycline and .Ceftizoxime E.coli was sensitive to Ceftizoxime (100%), Gentamicin (79.2%), Choloramphenicole (85.8%), (2 .Nalidixic acid (100%) and Amikacin (85.8%), and was resistant to Ceftazidime Staphylococcus was sensitive to Amikacin (100%), Tetracycline (100%), Gentamicin (100%), (3 Erytromicin (100%), Vancomycin (72.5%) and Cefalotin (72.5%), and was resistant to Oxaciline, .Ampicillin and Penicillin Enterobacter was sensitive to Tetracycline (100%), Erytromicin (100%), Ceftazidime (75%) and (4 .Vancomycin (50%), and was resistant to Cefalotin, Amikacin and Ampicillin Citrobacter freundii was sensitive to Nalidixic acid kanamycin (100%), Gentamicin (100%) and (5 Amikacin (66.6%), and was resistant to Cefalixine, Penicillin and Nitrofrantion. The bacterial infection was more common in male population (66.44%) compared with females (39.56%) and in children under

10 years old, it was the most prevalent cause (30%). The prevalence of wound infection was (74.4%), (urine infection was (23.5%) and Septicemia was (2.48%

Keywords: bacterial infection, antibiogram, burned patients, hospital

Introduction The human being is constantly exposed to heat injuries by different sources, and burning is one of the most common problems of human beings are facing with. One of the most important problems that may happen in burning is infection of burned area. For controlling this infection, recognizing of the existing epidemical grows in that area or more limited in burning center, and their antibiogram are vital for determining microbial sensitivity, because incorrect use of antibiotics can increase microbial resistance towards antibiotics and create potential resistant organisms that can reduce reaction to treatment. Pseudomonas is the most common pathogenetic organism isolated from spread infections which is still considered as an intense infection of wounds and death of burned patients. Urease staphylococcus is another pathogenetic organism that causes to destroy skin grafted tissue, and created in septicemia especially due to organism inside vein congestion. Considering the importance of affliction to nosocomial infections and patient fates, decision for accomplishment of these surveys for determining the frequency of bacterial infections and doing antibiogram test on these bacteria in burn ward of Zanjan Shafieh hospital was made. Accomplishing this survey will create the ability of using the most sensitive identified antibiotic when needed. Secondly, we can decrease the imposed costs on patients due to repeatedly changing of antibiotics or unreasonable use of some antibiotics. General target: studying the prevalence rate of bacterial infection and its antibiogram in hospitalized patients in burning ward of Zanjan Shafieh hospital. Special target: 1. Determining bacteria prevalence rate in burning infections. 2. Determining patients' age distribution in bacterial infections and finding the group exposed to danger.

3. Determining patients' sex distribution in bacterial infections. 4. Determining education degree of burned patients hospitalized in Shafieh hospital. 5. Determining sensitivity and resistance pattern of isolated bacteria against commonly used antibiotics. 6. Presenting proper scientific solutions for prevention of bacteria transmission.

Methodology The present research was written in 2008 by using the following procedure and information: A) Sampling: For accomplishing this survey that is an empirical one, I collected 91 clinical samples (wound, blood, urine…) by sampling method from burn ward of Zanjan Shafieh hospital from October 2002 till the end of September 2003. During these 12 months, permanent and continuous work has been performed on these samples. To do this, I went every day to the burn ward and took samples of patients in a correct way, using sterile cotton swab from burned parts. Then for studying and transferring the swab to this hospital microbiology laboratory, I placed it in transport environment (Nutrient bruth). This transport environment has been considered standard in all local and foreign sources, for working with burning samples. B) Collecting data: Full information of each patient referring to the burn ward via form No.1 was collected C) Isolating bacteria from clinical samples: I transferred samples collected from the burn ward to laboratory immediately for isolating and determining the type and species. To do this, I used Blood Agar culture and Maccanky culture environments as the screening test. Then by using warm coloring for specifying positive or negative warmth, I used special culture environments as a confirming test. Regarding positive warm cluster bacteria that were of

staphylococcus type, I used Mannitol Salt Agar culture and coagulase test and DNA Agar test as confirming tests and for diagnosis of species. For negative warm bacteria that are from Enterobacteriaceae family, I used Maccanky culture environment as the screening test and special culture environments such as Citrate Cimon, Urea, Sim, Methyl Redox Proscover, Triple Sugar Iren Agar (TSI) as confirming tests. Then I identified bacteria, by referring to table 2-1.

Chart (2-1): Distinctive specification of Enterobacteriaceae Survey method of studying antibiotic resistance spectrum (antibiogram) is as follows: Determining sensitivity of bacteria to antibiotics is very important in clinical cases. Knowing the microbe type is the basic part of illness treatment. But it may sometimes happen that determining the microbe sensitivity to medicine becomes more important, and it is when the treatment should be started quickly in acute cases. In laboratory, in order to study microbes' sensitivity to antimicrobial medicines different methods are used, such as;

1) Rarefaction preparing method 2) Agar diffusion disk preparing method 3) Taking from disk method

Results In this research, in order to study the title of prevalence of bacterial infections in burned patients and 91 clinical samples, sampling was done with a sterile swab, where 81 samples were positive and 10 samples were negative. 36 samples were contaminated by Pseudomonas aeruginosa (39.25%), 18 samples (19.2%) contaminated by Staphylococcus, and 8 clinical samples (8.72%) contaminated by Enterobacter, 3 clinical samples (3.27%) contaminated by Citrobacter freundii and 1 clinical sample (1.09%) contaminated by Klebsiella. In this survey, 60 clinical samples were culture of wound (74.40%), 19 samples culture of urine (23.56%) and 2 samples were culture of blood (2.48%). The existing bacteria in patients' wounds are as follows: Pseudomonas (41.5%), Escherichia coli (16.6%), Staphylococcus (31.58%), Enterobacter (13.28%), Citrobacter freundii (4.98%) and Klebsiella (1.66%) (Table3-3). In urine culture too, Pseudomonas (57.86%), Escherichia coli (26.30%), Staphylococcus (15.78%) were found (Table3-4). 2 samples of blood culture were positive that one sample was positive Staphylococcus coagulase and the other one was negative coagulase (Table3-5). All bacteria isolated from clinical samples were tested by antibiogram test to specify their sensitivity and resistance to a common antibiotic the results of which have been shown in tables (3-6, 3-7, 3-8, 3-9 and 3-10). Age distribution of patients has been studied in age groups. The most prevalent burning age was in the age group under 15 years old (Chart 3-2). Statistic Kaidu test showed that the difference in this age group is statistically significant (p<0.01). Sex distribution of under-study patients included 25 men (39.56%) and 46 women (60.44%) and in view of sex, burning prevalence was more in female group (Chart 3-3) that statistic test did not show significant correlation between burn infections and sex. Also distribution of education

degree showed that 42 persons (78%) were illiterate, 18 persons (30.52%) had elementary school degree, 16 persons (17.44%) had high school diploma, and 5 persons (5.45%) had higher degree (Chart 3-4). It seems that infection is still the most common cause of death in burned patients. Burning causes intense suppression of immunity. Generally, the lack of immunity make burned patients susceptible to infection. On the other hand, these isolated bacteria have become resistant to antimicrobial factors, and due to sensitivity of natural fluorine bacteria to these antimicrobial factors, resistant organisms replace these bacteria. Because of unbalance of reaction between opportunist and host microorganisms, these bacteria enter easily in circulatory system, and create poison and consequently death in the aged and children, due to the weakness of immune system. Although confronting with these infections and destroying them completely is very difficult in burnings, but I can suggest some effective ways in controlling them, as follows: 1) Immediate transfer of burned patient to hospital and hospitalizing him in aseptic quarantine ward. 2) Quick use of topical antimicrobial materials and dressing of wounds. 3) Microbial surveys of different parts and hospital facilities, and in case of observing this microorganism, necessary actions should be taken to destroy it. 4) Checking all personnel working in burn ward and in contact with patient, and in case of finding Urease Staphylococcus in their nose and hand, they should be treated in a suitable way (Bacitracin ointment and edible Rifampin). 5) Limiting entrance of unknown and unstudied people to the ward and preventing their contact with the patient. 6) Complete and continuous disinfecting of dressing wound room and following hygienic principles by personnel of dressing wound room.

Tables and Charts

Frequency Type of

Number

Percent

microorganism Pseudomonas

36

39.25%

Escherichia coli

15

16.35%

PositiveStaphylococcus

14

15.26%

Enterobacter

8

8.72%

NegativeStaphylococcus

4

3.36%

Citrobacter Freundii

3

3.27%

Klebsiella

1

1.09%

Negative growth

10

10.9%

Total

91

100%

aeruginosa

Coagulase

Coagulase

Table (3-1): Frequency distribution of microorganisms isolated from patients hospitalized in (burn ward of Zanjan Shafieh hospital (2007

Sex

Female

Freq. Kind

Male

Total

Percent Number Percent Number

Number

Percent

60

74.40%

of infection Wound

36

44.64

infection Urine

24

%

29.76 %

9

11.16%

10

12.4%

19

23.56%

Septicemia

1

1.24%

1

1.24%

2

2.48%

Total

46

57.04

35

43.40

81

100

infection

%

%

Table (3-2): Studying frequency of all types of infection in terms of sex in burned patients (hospitalized in burn ward of Zanjan Shafieh hospital according to sex (2007

Frequency Kind of

Number

Percent

25

41.5%

10

16.6%

bacteria Pseudomonas aeruginosa Escherichia coli

Positive

11

18.26%

Enterobacter

8

13.28%

Negative

2

3.32%

Citrobacter Freundii

3

4.98%

Klebsiella

1

1.66%

Total

60

100%

Staphylococcus Coagulase

Staphylococcus Coagulase

Table (3-3): Frequency distribution of bacteria existing in wound of burned patients hospitalized (in burn ward of Zanjan Shafieh hospital (2007

Frequency Kind of

Number

Percent

11

57.86%

5

26.30%

microorganism Pseudomonas aeruginosa Escherichia coli

Positive

2

10.52%

1

5.26%

19

100%

Staphylococcus Coagulase Negative Staphylococcus Coagulase Total

Table (3-4): Frequency distribution of bacteria existing in urine of burned patients hospitalized (in burn ward of Zanjan Shafieh hospital (2007

Sensitivity

Female

Male

Total

Freq. Number

Percent Number Percent

Percent Number

Type of bacteria Negative Staphylococcus 1

50%

0

0

1

50%

0

1

50%

1

50%

50%

2

100

Coagulase Negative Staphylococcus

0

Coagulase

Total

1

50%

1

Table (3-5): Frequency distribution of bacteria existing in blood of burned patients hospitalized (in burn ward of Zanjan Shafieh hospital according to sex (2007

Sensitivity

Sensitive

Intermediate

Resistant

sensitive Freq. Antibiotic

Number

Percent Number Percent

Percent Number

Amikacin

31

86%

Ciprofloxacin

28

75.6%

Gentamicin

20

Norfloxacin

8

5.4%

3

8.1%

4

10.8%

4

10.8%

54%

4

10.8%

12

32.4%

21.6%

4

10.8%

3

8.1%

27

72.9%

8.1%

30

81%

Tubramycin

6

16.2%

Ceftrioxon

3

8.1%

Ceftazidime

0

0

2

3 0

0

24

36

64.8%

100%

Tetracycline

0

0

0

0

36

100%

Ceftizoxime

0

0

0

0

36

100%

Table (3-6): Frequency distribution of Pseudomonas aeruginosa sensitivity and resistance to (common antibiotics in hospitalized patients in burn ward of Zanjan Shafieh hospital (2007

Sensitivity

Sensitive

Intermediate

Resistant

sensitive Freq. Antibiotic

Percent

Percent Number

Number

Percent Number

Ceftizoxime

15

100%

12

79.2%

0

0

0

0

1

6.6%

2

13.2%

1

6.6%

Gentamicin

Choloramphenicole

13

85.8%

1

6.6%

Nalidixic acid

15

100%

0

0

1

% 6.6

12

79.2%

26.4%

1

6.6%

Ampicillin

2

13.2%

Cefalotin

10

66%

Amikacin

13

85.8%

Tubracin

3

19.8%

4 1

0

6.6%

0

0

0

1 12

6.6% 79.2%

Table (3-7): Frequency distribution of Escherichia coli sensitivity and resistance rate to common (antibiotics in hospitalized patients in burn ward of Zanjan Shafieh hospital (2007

Sensitivity

Sensitive

Intermediate

Resistant

sensitive Freq.

Number Percent Number Percent Number Percent

Antibiotic Amikacin

18

100%

0

0

0

0

Tetracycline

18

100%

0

0

0

0

Gentamicin

18

100%

0

0

0

0

Erytromicin

18

100%

0

0

0

0

Vancomycin

13

72.5%

0

0

5

27.5%

Cefalotin

13

72.5%

0

0

5

27.5%

Oxaciline

0

0

0

0

18

100%

Ampicillin

0

0

0

0

18

100%

Penicillin

0

0

0

0

18

100%

Table (3-8): Frequency distribution of Staphylococcus sensitivity and resistance rate to common (antibiotics in hospitalized patients in burn ward of Zanjan Shafieh hospital (2007

Sensitivity

Sensitive

Intermediate

Freq.

Resistant

sensitive Number Percent Number Percent Number Percent

Antibiotic Tetracycline

8

100%

0

0

0

0

Erytromicin

8

100%

0

0

0

0

Ceftazidime

8

100%

0

0

0

0

Gentamicin

6

75%

1

125%

1

12.5%

Vancomycin

4

50%

3

27.5%

1

12.5%

Cefalotin

0

0

0

0

8

100%

Amikacin

0

0

0

0

8

100%

Ampicillin

0

0

0

0

8

100%

Table (3-9): Frequency distribution of Enterobacter sensitivity and resistance rate to common (antibiotics in hospitalized patients in burn ward of Zanjan Shafieh hospital (2007

Sensitivity

Sensitive

Intermediate

Resistant

sensitive Freq. Number Percent Number Percent Number Percent Antibiotic Nalidixicacid 3

100%

0

0

0

0

Kanamycin

3

100%

0

0

0

0

Gentamicin

3

100%

0

0

0

0

Amikacin

2

66.6%

0

0

1

33.4%

Cefalixine

0

0

0

0

3

100%

Nitrofrantoin

0

0

0

0

3

100%

Penicillin

0

0

0

0

3

100%

Table (3-10): Frequency distribution of Citrobacter freundii sensitivity and resistance rate to (common antibiotics in patients hospitalized in burn ward of Zanjan Shafieh hospital (2007

Chart (3-1): Frequency of infection in burned patients hospitalized in burn ward of Zanjan (Shafieh hospital (2007

(Chart (3-2): Age distribution of burned patients in burn ward of Zanjan Shafieh hospital (2007

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