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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 106-112
Original article
Aerobic bacterial infections in a burns unit of Sassoon General
Hospital, Pune
Patil P, Joshi S, Bharadwaj R.
Department of Microbiology, B.J. Medical College, Pune, India.
Corresponding author: Dr. Priyanka Patil
Abstract:
Introduction: Infection in the burn patient is a leading cause of morbidity and mortality and remains one of the most
challenging concerns for the burn team. For this reason we carried out a study to determine the predominant bacteria causing
infections and their antimicrobial susceptibility pattern.
Methods: A prospective cross sectional study over a period of three months was carried out in burns unit of Sassoon
General Hospital, Pune. A total of 51 surface wound swab specimens from 39 patients were collected and processed
aerobically. All isolates were identified by conventional microbiological methods and their antibiogram was determined as
per CLSI guidelines.
Results: 81 isolates were obtained from 51 specimens. Out of them, 26 (50.98%) specimens were mono-microbial while 25
(49.01%) specimens were poly-microbial. Pseudomonas aeruginosa was the most common isolate 22 (27.61%) followed by
Klebsiella species 13, 16.04%), Staphylococcus aureus (MRSA) (12, 14.81%). Both gram positive and gram negative
isolates show widespread resistance to first-line antibiotics. While they are relatively sensitive to second line agents which
are considered as reserved drugs.
Conclusion: Our results were helpful in providing guidelines regarding empirical antimicrobial treatment in burns patients
before the results of microbiological culture became available.
Key words: burn wound, Antimicrobial resistance, Pseudomonas aeruginosa
Introduction
surveillance is needed. So the current study was
Burn injury is one of the most common and
undertaken to assess predominant aerobic microbial
devastating forms of trauma in many areas of the
flora and their antibiogram in burns unit of Sassoon
world. It has been estimated that 75% of all deaths
General Hospital, Pune.
following
Aims & Objectives
infections.
thermal
(1)
injuries
are
related
to
The rate of nosocomial infections is
To determine the predominant bacteria and their
higher in burn patients due to various factors like
antimicrobial
susceptibility
pattern
nature of burn injury itself, immunocompromised
infections in burn wound patients.
status of the patient, invasive diagnostic and
Material & Methods
causing
(2)
The present study was conducted in the Department
Good infection control practices have a great
of Microbiology, Sassoon General Hospital, Pune.
impact on survival rate of burn patients. Emerging
This was a prospective cross sectional study.
antimicrobial resistance in burn wound bacterial
Among the admitted patients, thirty nine randomly
pathogens represent a serious therapeutic challenge
selected patients who gave consent were included
for clinicians treating these patients. In order to
the study. A total of 51 surface burn wound swabs
overcome this problem continuous microbiological
were collected from 39 patients (13 males & 26
therapeutic procedures and prolonged ICU stay.
106
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ISSN: 2319-7072
International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 106-112
females) over a period of three months from June-
conventional
microbiological
methods.
August 2010. Extent of burn injury ranged from
Antimicrobial susceptibility pattern was determined
(15%-70%). These Patients were not having
as per Clinical and Laboratory Standard Institute
infected wound at the time of admission. Burn
(CLSI) guidelines.
wound infection was evident after one week stay in
To assess the differences in the range of bacterial
the hospital. All specimens were transported in
pathogens in male & female wards, they were
sterile, leak-proof container to Department of
studied &analyzed separately. Re-sampling was
Microbiology. They were processed for aerobic
done in 6 patients who were not responding to
bacterial pathogens &isolates were identified by
treatment.
Fig. 1: Schematic Representation of Burns Unit of Sassoon General Hospital, Pune.
Observation & results
Out of 51 specimens, single organism was isolated in 25(49%) specimens while mixed organisms were isolated
in 26(51%). Total 81 isolates were obtained.
Table 1: Distribution of aerobic bacterial isolates (n=81)
ISOLATES
NO
Percentage (%)
Pseudomonas aeruginosa
22
27
Klebsiella pneumonae
13
16
MRSA
12
15
Citrobacter spp.
11
13
Escherichia coli
10
12
Proteus mirabilis
5
6
Enterobacter spp.
3
4
Acinetobacter spp.
3
4
2
3
81
100
Coagulase negative staphylococci
TOTAL
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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 106-112
the
In this study, we have compared antibiogram of
Klebsiella
pathogens obtained from male and female wards.
pneumonae 13(16%) and MRSA 12(15%). (Table
The antibiogram of Gram negative organisms
1)
isolated from burn wound is shown in Table 2.
Pseudomonas
commonest
22(27%)
aeruginosa
isolate
followed
was
by
Table 2: Antimicrobial Sensitivity Pattern of Gram negative isolates in male & female wards
Escherichia coli
Citrobacter spp. (n=11)
(n=10)
Female
Male
Female
Male
Female
ward
ward
ward
ward
ward
ward
isolates
isolates
isolates
isolate
isolates
isolate
n=4
n=6
n=6
n=5
n=8
n=5
Sensitivity
CRO
SXT
G
CIP
T
IPM
PTZ
(n=13)
Male
AMA
AK
Klebsiella pneumonae
NO
%
NO
%
NO
%
NO
%
NO
%
NO
%
S
0
0
0
0
0
0
1
20
0
0
0
0
R
4
100
6
100
6
100
4
80
8
100
5
100
S
0
0
1
16.6
1
16.6
0
0
0
0
0
0
R
4
100
5
83.4
5
83.4
5
100
8
100
5
100
S
0
0
0
0
0
0
0
0
0
0
0
0
R
4
100
6
100
6
100
5
100
8
100
5
100
S
0
0
0
0
0
0
0
0
0
0
0
0
R
4
100
6
100
6
100
5
100
8
100
5
100
S
1
25
1
16.6
3
50
2
40
2
25
1
20
R
3
75
5
83.4
3
50
3
60
6
75
4
80
S
1
25
2
33.3
2
33.3
1
20
1
12.5
2
40
R
3
75
5
66.7
5
66.7
4
80
7
87.5
3
60
S
4
100
6
100
6
100
0
0
6
75
4
80
R
0
0
0
0
0
0
5
100
2
25
1
20
S
4
100
6
100
0
100
4
80
7
87.5
4
80
R
0
0
0
0
6
0
1
20
1
12.5
1
20
AMA = Antimicrobial agent, AK = Amikacin,
Ceftriaxone,
Cotrimoxazole,
and
Gentamicin.
CRO = Ceftriaxone, SXT = Cotrimoxazole, G =
E.coli and Citrobacter spp. were 100% sensitive to
Gentamicin, CIP = Ciprofloxacin, T = Tetracycline,
Imipenem and Piperacillin-Tazobactum. Sensitivity
IPM = Imipenem, PTZ = Piperacillin-Tazobactum,
pattern from both male and female wards doesn’t
S = Susceptible, R = Resistant.
show much difference. (Table 2)
E.coli, Klebsiella spp. and Citrobacter spp. were
highly resistance to first line drugs like Amikacin,
Table 3: Antimicrobial Sensitivity Pattern of Pseudomonas aeruginosa in male & female wards
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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 106-112
Pseudomonas aeruginosa (n=22)
AMA
AK
CAZ
CB
G
CIP
T
IPM
PTZ
Sensitivity
Male
Female
ward
ward
isolates
isolates
n=8
n=14
NO
%
NO
%
S
0
0
0
0
R
8
100
14
100
S
0
0
1
7.2
R
8
100
13
92.8
S
0
0
6
42.9
R
8
100
8
57.1
S
1
12.5
2
14.3
R
7
87.5
12
85.7
S
2
25
4
28.6
R
6
75
10
71.4
S
2
25
1
7.2
R
6
75
13
92.8
S
8
100
13
92.9
R
0
0
1
7.1
S
7
87.5
12
85.7
R
1
12.5
2
14.3
AMA = Antimicrobial agent, AK = Amikacin,
This table shows Pseudomonas aeruginosa was
CAZ = Ceftazidime, CB = Carbenicillin, G =
highly sensitive to Imipenem (male ward 100%,
Gentamicin, CIP = Ciprofloxacin, T = Tetracycline,
female ward 93%) followed by Piperacillin-
IPM = Imipenem, PTZ = Piperacillin-Tazobactum,
Tazobactum (male ward 87.5%, female ward
S = Susceptible, R = Resistant.
85.7%). Organisms were sensitive to Ciprofloxacin
to some extent among first line drugs. (Table 3)
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Table 4: Antimicrobial Sensitivity Pattern of MRSA in Male and Female wards
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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 106-112
MRSA(n=12)
Male
AMA
PEN
SXT
G
E
CIP
CD
VAN
ward
Female ward
isolates
isolates
(n=6)
(n=6)
Sensitivity
NO
%
NO
%
S
0
0
0
0
R
6
100
6
100
S
0
0
0
0
R
6
100
6
100
S
0
0
0
0
R
6
100
6
100
S
0
0
0
0
R
6
100
6
100
S
2
33.3
1
16.7
R
4
66.7
5
83.3
S
2
33.3
2
33.3
R
4
66.7
4
66.7
S
6
100
6
100
R
0
0
0
0
AMA = Antimicrobial agent, PEN = Penicillin,
shown (Table 4). Staphylococcus aureus were
SXT= Cotrimoxazole, G = Gentamicin, E =
100%
Erythromycin,
CIP
Clindamycin,
VAN
=
Ciprofloxacin,
=
Vancomycin,
Sensitivity
to penicillin,
Cotrimoxazole,
CD
=
Gentamicin, Erythromycin while they were 100%
S
=
sensitive to Vancomycin followed by Clindamycin
Susceptible, R = Resistant.
Antimicrobial
resistant
(33.3%).
Pattern
of
Staphylococcus aureus isolated from burn wound is
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TABLE 5: Time Related Changes in organism isolated
Patient No.
M1
M2
1st sample
2nd sample
P.aeruginosa
MRSA, K.pneumoniae, E. coli
P.aeruginosa
K.pneumoniae, Pr.mirabilis, CONS
P.aeruginosa, K.pneumoniae,
M3
M4
Citrobacter spp
K.pneumoniae, Pr.mirabilis, CONS
MRSA, K.pneumoniae
K.pneumoniae, Pr.mirabilis, CONS
E.coli
K.pneumoniae, Pr.mirabilis, CONS
E.coli, P.aeruginosa
E.coli , P.aeruginosa
MRSA
K.pneumoniae
F1
F2
F3
(7, 8)
When re-sampling was done in 6 patients who were
other studies
not responding to treatment we found the change in
threat in our hospital.
colonizing organisms. (Table 5)
Fig. 1 shows the schematic representation of
Discussion
different burn wards in Sassoon General Hospital,
Infection with multi-drug resistant organisms is an
Pune. Here we have compared the isolates and
important cause of mortality in burns. These
sensitivity pattern from male and female wards.
organisms have frequently been reported as the
Since isolates from these wards were having almost
cause of nosocomial outbreaks of infection in burn
similar sensitivity they are most likely to be
units or as colonizers of the wounds of burn
hospital acquired.
patients.
(3, 4)
, Acinetobacter was not a big
E. coli, Klebsiella spp. and Citrobacter spp. were
In the present study, P.aeruginosa (27%) was
highly resistance to first line drugs like Amikacin,
found to be predominant pathogen followed by
Ceftriaxone, Cotrimoxazole, and Gentamicin while
K.pneumoniae (16%) & MRSA (15%). This is
they were 100% sensitive to Imipenem and
consistent with other studies.
(5, 6, 7, 8)
In contrast to
Piperacillin-Tazobactum. This is consistent with
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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 106-112
(5, 6)
other studies.
surveillance should be the ongoing process to
Staphylococcus aureus isolates
were 100% resistant to Penicillin, Cotrimoxazole,
determine change in colonizing bacteria.
Gentamicin, and Erythromycin. These isolates were
Based on the study we recommend the following:
found to be 100% sensitive to Vancomycin. This is
consistent with other study.
•
(5)
Every institution having burns unit should
periodically to determine predominant
In this study, we have found that both gram
flora causing burn wound colonization and
positive
show
their antimicrobial susceptibility pattern.
widespread resistance to first-line antibiotics.
This would help in administration of
While they are relatively sensitive to second line
proper empirical antimicrobial treatment
agents which are considered as reserved drugs. This
before microbial culture reports become
could be due to indiscriminate use of first line
available.
and
antibiotics
gram
leading
population
of
negative
to
isolates
selective
pressure
bacteria.Re-sampling
in
•
Due
to
high
isolation
rates
of
showed
microorganisms and high antimicrobial
changes in bacterial flora in patient’s burn wound.
resistance it is crucial to improve infection
This necessitates periodic sampling of the wound
control practices like hand washing,
sample over the hospital stay.
barrier nursing, isolation of infected
Conclusion
persons, and culture & sensitivity for the
This study would be helpful for the determination
wound of the patients not responding to
of antimicrobial policy of hospital. Microbiological
empirical treatment.
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