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MLS00170 - BACTERIAL PROFILE AND DRUG RESISTANCE PATTERN OF PATHOGENS ISOLATED FROM WOUND INFECTION AT THE STATE SPECIALIST HOSPITAL, AKURE, ONDO STATE


CHAPTER ONE

INTRODUCTION

1.1       Background of the study

Wound is a breach in the skin and the exposure of subcutaneous tissue following loss of skin integrity (Nitinet al., 2013). The exposed subcutaneous tissues provide a favorable substratum for a wide variety of microorganisms to contaminate and colonize, and if the involved tissue is devitalized and the host immune response is compromised, the conditions become optimal for microbial growth. This is because the host immune response plays a critical role in determining whether wound infection will arise (Esebelahieet al., 2013).

 Wounds can be classified as accidental, pathological or post-operative. Whatever the nature of the wound, infection is the attachment of microorganisms to host cells and they proliferate, colonize and become better placed to cause damage to the host tissues (Mordi and Momoh, 2009; Mohammad et al., 2013).

Wounds can also broadly categorize as having either an acute or a chronic etiology. Acute wounds are caused by external damage to intact skin and include surgical wounds, bites, burns, minor cuts and abrasions, and more severe traumatic wounds such as lacerations and those caused by crush or gunshot injuries. In marked contrast, chronic wounds are most frequently caused by endogenous mechanisms associated with a predisposing condition that ultimately compromises the integrity of dermal and epidermal tissue (Bowler et al., 2001).

All wounds are contaminated by both pathogens and body commensals. But The progression of a wound to an infected state is likely to involve a multitude of microbial or host factors .These may be the microbial load, and the combined virulence expressed by the types of microorganisms involved, patient risk factors like the general health and immune status of the host ,diabetes, cigarette smoking, obesity, and coincident remote site infections or colonization and operation-related risk factors including prolonged hospital stay before surgery, duration of the operation, tissue trauma, poor hemeostasis and foreign material in the wound, with these last greatly increasing the risk of serious infection despite a relatively small bacterial inoculums (Rubin, 2009;  Saniet al., 2012; Esebelahie et al., 2013)

Wound can be infected by a variety of microorganisms ranging from bacteria to fungus and parasites. Both acute and chronic wounds are susceptible to contamination and colonization by a wide variety of aerobic and anaerobic microorganisms (Bowler et al., 2001). Isolates that have been incriminated in cases of wound infections include: Staphylococcus aureus, Staphylococcus epidermidis,Streptococcus faecalis, Streptococcus pyogenes, Proteus mirabilis, Pseudomonas aeruginosaKlebsiellaspp, Escherichia coli, , Acinetobacter, and Enterobacter .Candida albicans and C. tropicalishave also been implicated as etiological agents (Egbeet al., 2011; Mohammed et al., 2013)

The majority of wounds are characterized by a polymicrobial aerobic-anaerobic microflora; therefore, the careful use of broad spectrum antimicrobial agents is likely to be the most successful treatment in the management of infected wound. However, various antibiotics are frequently and sometimes inappropriately prescribed or administered in wound treatments, which often leads to the selection of antibiotic-resistant bacteria strains (Adenike et al., 2012).  Antimicrobial resistance among pathogens of wound infections is on the increase (Adegoke et al., 2010).

Antibiotic resistance is an emerging global health crisis, resulting from the continuous use (and misuse) of antibiotics in healthcare, farming industry, and elsewhere (Cantas et al., 2013; World Health Organization WHO, 2014).

Antimicrobial drug resistance can be acquired as a result of mutation or acquisition of resistance genes via horizontal gene transfer, or can be an innate feature of an organism that is encoded chromosomally (Livermore, 2002). Antimicrobial drugs overuse, over dosing, drugs prescription with improper susceptibility test, self-medication and long duration of hospitalization was suggested to augment the problem of multi-drug resistant (MDR) in developing nations (Girmaet al., 2013).Therefore, continual usage of  systemic and topical antimicrobial agents has provided the selective pressure that has led to the emergence of antibiotic resistant strains, available therapeutic options for such organisms are severely limited which in turn, has driven the  continued search for new agents. Unfortunately, the increased costs of searching for effective antimicrobial agents and the decreased rate of new drug discovery have made the situation increasingly worrisome (Mama et al., 2014).

Antimicrobial resistance is not only increasing the healthcare costs but also the severity and death rates from certain infections that could have been avoided by prudent and rational use of the existing and newer antimicrobial agents. Emerging multidrug resistant strains and changing antimicrobial resistance pose challenge in treating wound infections. This study will guide the clinician in choosing appropriate antimicrobials which not only contribute to better treatment but their judicious use will also help in preventing emergence of resistance to the drugs which are still sensitive.

1.2       Statement of Problems

Since wound colonization is most frequently polymicrobial involving numerous microorganisms that are potentially pathogenic, any wound is at some risk of becoming infected. In the event of infection, a wound fails to heal, the patient suffers increased trauma, treatment costs rise, and general wound management practices become more resource demanding.5 Infection continues to be a major complication of wounds with significant increase morbidity and potential mortality (Mohammed et al., 2013). Wound infection is one of the most challenging aspects of wound management and a major contributor to healthcare costs globally (Harding and Renyi, 2009). Wound infections may occur following accidental trauma and injections, but post-operative wound infections in hospital are most common (Mohammed et al., 2013).

Wound infections are the most expensive complications following surgery and moreover, it is thought to be second most common type of nosocomial infections (Praveen and Doddmani, 2013). Nosocomial infections (NIs) are the infections acquired during hospital stay and are widespread. They are important contributors to morbidity and mortality. These infections concern 2 million cases annually worldwide i.e., 5-15 per cent of hospitalized patients and up to 10 per cent of patients acquire more than one of these infections (Anushaet al., 2010).

The rate of surgical site infection (SSI) varies greatly worldwide and from hospital to hospital. In European hospitals, the overall rates of SSI range between 3 % and 4 % of patients undergoing surgery. Depending on the nature of surgery in question, the incidence of SSI ranges between <1% to >10 % (Chandan et al., 2009). Epidemiological Study of Surgical Wound Infections conducted in India reported that the annual incidence of SSI to be 30.2 patients per 1000 patients (Anushaet al., 2010). It has been estimated that that 500,000 SSIs occur annually in the United Statesand account for approximately one quarter of the estimated 2 million NI in the United States (Suchitra et al., 2009). In Africa the rate of SSIs varied from 2.5 % to 30.9 % following various types of surgical procedures (Sepidehet al 2011). Studies have shown that the average hospital stays doubled and that the cost of hospitalization was correspondingly increased when postoperative surgical wound infection developed (Suchitra et al., 2009). A study from Ethiopia reported that the mean postoperative stay and mortality were significantly higher in patients with surgical site infection compared with in uninfected patients (Taye, 2005). One to two percent of the population in the developed countries will experience a chronic wound in their lifetime. In united state chronic wounds affect around 6.5 million patients. It is claimed that an excess of US$25 billion is spent annually on treatment of chronic wounds and it is expected that the number of chronic wounds will increase worldwide due to the increase of lifestyle diseases, such as diabetes, obesity, and cardiovascular diseases (Chandan et al., 2009).

The rapid emergence of antimicrobial resistance among bacteria is a public health crisis. Wound Infections with antimicrobial-resistant bacteria increase patient morbidity and mortality and greatly increase the cost of medical care (Theoklis, 2009). The control of wound infections has become more challenging due to widespread bacterial resistance to antibiotics and to a greater incidence of infections caused by methicillin resistant S. aureus(MRSA) and polymicrobic flora (Saniet al., 2012).

1.3       Significance of the Study

The current worldwide increase in resistant bacteria and the simultaneous downward trend in the discovery of novel antibacterial agents to combat resistant strains is a serious threat to the treatment of life-threatening infections. The existence of bacteria resistant to topical and systemic antibiotics dramatically reduces the possibilities of treating infected wounds effectively and results in delayed wound healing and complications such as septicaemia that may lead to death (Vazquez, 2006). There are currently no new classes of effective antibacterial compounds, which can prevent or treat antibiotic resistant bacterial infections (Falconer and Brown, 2009). Therefore there is a drive to develop novel therapies to control these pathogens and that to which pathogens will not easily develop resistance (Taylor et al., 2002). Antimicrobials provide the main basis for the therapy of microbial infections.The inevitable consequence of the widespread use of antimicrobial agents has been the emergence of antimicrobial resistant pathogens.

Pus infection patients are subjected to several factors that may be associated with multidrug resistant microorganism carriage such as inappropriate antibiotic treatment, chronic course of the wound and frequent hospital admission (Kandemiret al, 2007).

In Nigeria there has been limited data regarding the magnitude of wound infections due to antimicrobial resistant pathogens as well as resistance to commonly prescribed antibiotics used in treatment of these infections. This gap makes the choice of empirical therapy more difficult to the clinician. Rational use of antibiotics is known to improve treatment outcome, shortens duration of hospital stay and reduces the cost of treatment. This requires continuous surveillance and update profile of antimicrobial susceptibility pattern

Though, several studies have been conducted on etiology of wound infections in Nigeria, none of them

adequately addressed the extent of drug resistance of these isolates against different antimicrobial classes.

Therefore, this study was intended to determine the magnitude of MDR bacteria identified from infectedwounds in order to provide locally applicable data and to guide empirical therapy in area where culture anddrug susceptibility testing facilities are scarce.

 

1.4       AIM

The aim of this study is to determine the bacterial profile and drug resistant pathogenic isolate from wound infection at State Specialist Hospital, Akure.

1.5       Objectives

 

  1. To determine the prevalence of bacterial wound infection at State Specialist Hospital,Akure
  2. To determine the bacterial pathogens responsible for the wound infection in State Specialist Hospital,Akure
  3. To determine the antimicrobial resistance pattern of commonly isolated wound microbes State Specialist Hospital,Akure

 

1.6 Hypothesis

  1. There is no significant difference in determine the prevalence of bacterial wound infection at State Specialist Hospital Akure.
  2. There is no significant distribution in determining bacterial pathogen responsible for wound infection in State Specialist Hospital, Akure.
  3. There is no significant investigation in determining the antimicrobial resistant pattern of commonly isolated wound microbe in State Specialist Hospital, Akure.